Provider Demographics
NPI:1346300621
Name:SHORT, SUSAN WAITES (PT, MSPT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:WAITES
Last Name:SHORT
Suffix:
Gender:F
Credentials:PT, MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 N BROOKMOORE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2024
Mailing Address - Country:US
Mailing Address - Phone:662-327-6705
Mailing Address - Fax:662-327-6760
Practice Address - Street 1:3102 RAINBOW DR STE 200
Practice Address - Street 2:
Practice Address - City:RAINBOW CITY
Practice Address - State:AL
Practice Address - Zip Code:35906-5804
Practice Address - Country:US
Practice Address - Phone:256-549-6387
Practice Address - Fax:256-549-6391
Is Sole Proprietor?:No
Enumeration Date:2006-12-09
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH4115225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist