Provider Demographics
NPI:1326051822
Name:HEARN, SUE ANN CLARK (PT)
Entity Type:Individual
Prefix:MRS
First Name:SUE ANN
Middle Name:CLARK
Last Name:HEARN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6555 ABERCORN ST STE 221
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5714
Mailing Address - Country:US
Mailing Address - Phone:912-354-4474
Mailing Address - Fax:912-354-4443
Practice Address - Street 1:6555 ABERCORN ST STE 221
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5714
Practice Address - Country:US
Practice Address - Phone:912-354-4474
Practice Address - Fax:912-354-4443
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT002390174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00608704BMedicaid
GAPT002390OtherPT LICENSE