Provider Demographics
NPI:1417019092
Name:BURNETT, SUSANNE WATSON (R PT)
Entity Type:Individual
Prefix:MRS
First Name:SUSANNE
Middle Name:WATSON
Last Name:BURNETT
Suffix:
Gender:F
Credentials:R PT
Other - Prefix:MISS
Other - First Name:SUSANNE
Other - Middle Name:WATSON
Other - Last Name:BABB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1060 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4433
Mailing Address - Country:US
Mailing Address - Phone:928-649-8663
Mailing Address - Fax:
Practice Address - Street 1:1500 S MONTE TESORO DR
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-6232
Practice Address - Country:US
Practice Address - Phone:928-634-7039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3952225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1741OtherP.T. LICENSE
AZ920042Medicaid