Provider Demographics
NPI:1457311201
Name:WHITE, SUSAN (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WHITE
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:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:WEST TISBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02575-0547
Mailing Address - Country:US
Mailing Address - Phone:508-693-5949
Mailing Address - Fax:
Practice Address - Street 1:12 COURNOYER ROAD
Practice Address - Street 2:
Practice Address - City:WEST TISBURY
Practice Address - State:MA
Practice Address - Zip Code:02575
Practice Address - Country:US
Practice Address - Phone:508-693-5949
Practice Address - Fax:508-693-5942
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2007-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4766225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAA39271OtherHARVARD PILGRIM
MAY67597OtherBLUE CROSS BLUE SHIELD
MA0315711Medicaid
MAQX3256Medicare PIN