Provider Demographics
NPI:1255509766
Name:CHALELA, SUSAN K
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:CHALELA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1476 LONG GROVE DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7571
Mailing Address - Country:US
Mailing Address - Phone:843-216-3534
Mailing Address - Fax:843-216-3576
Practice Address - Street 1:1476 LONG GROVE DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7571
Practice Address - Country:US
Practice Address - Phone:843-216-3534
Practice Address - Fax:843-216-3576
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5484225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1903Medicaid
SCQ347518702Medicare PIN