Provider Demographics
NPI:1255473856
Name:WILLIAMS, SUSAN LYNN (DC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5943
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5943
Mailing Address - Country:US
Mailing Address - Phone:765-448-6489
Mailing Address - Fax:765-448-9775
Practice Address - Street 1:134 EXECUTIVE DR
Practice Address - Street 2:SUITE 3
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905
Practice Address - Country:US
Practice Address - Phone:765-448-6489
Practice Address - Fax:765-448-9775
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN008001427A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
10787204OtherCAQH
IN200129120AMedicaid
350054830OtherRRMM
IN200129120AMedicaid
350054830OtherRRMM