Provider Demographics
NPI:1376505289
Name:DEKING, SUSAN J (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:DEKING
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 1:8390 OSWEGO RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090
Mailing Address - Country:US
Mailing Address - Phone:315-652-4323
Mailing Address - Fax:315-622-1110
Practice Address - Street 1:12010 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:NY
Practice Address - Zip Code:14590
Practice Address - Country:US
Practice Address - Phone:315-594-6124
Practice Address - Fax:315-594-2182
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0195601225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02303973Medicaid
NYCC1516Medicare ID - Type Unspecified
P11955Medicare UPIN