Provider Demographics
NPI:1366691321
Name:KANCHARLA, SUSMITHA (PT)
Entity Type:Individual
Prefix:
First Name:SUSMITHA
Middle Name:
Last Name:KANCHARLA
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 1:2156 BLUEBONNET LN
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-8558
Mailing Address - Country:US
Mailing Address - Phone:704-502-8892
Mailing Address - Fax:
Practice Address - Street 1:13150 DORMAN RD
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28134-9382
Practice Address - Country:US
Practice Address - Phone:704-542-0312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10396225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist