Provider Demographics
NPI:1447398516
Name:VERGILIO, SUSAN ROSE (OTR)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ROSE
Last Name:VERGILIO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ROSE
Other - Last Name:WALLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:13850 E 12 MILE RD
Mailing Address - Street 2:STE 2A
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-3730
Mailing Address - Country:US
Mailing Address - Phone:586-552-4499
Mailing Address - Fax:586-552-4878
Practice Address - Street 1:13850 E 12 MILE RD
Practice Address - Street 2:STE 2A
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-3730
Practice Address - Country:US
Practice Address - Phone:586-552-4499
Practice Address - Fax:586-552-4878
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003254225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201003254OtherLICENSE
MIP11090001Medicare ID - Type UnspecifiedMEDICARE
MIQ36927Medicare UPIN