Provider Demographics
NPI:1457675563
Name:TATE, SUSAN R (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:R
Last Name:TATE
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3006 MCNIEL AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76309-4954
Mailing Address - Country:US
Mailing Address - Phone:940-867-9567
Mailing Address - Fax:940-867-9567
Practice Address - Street 1:3006 MCNEIL AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76309-4954
Practice Address - Country:US
Practice Address - Phone:940-867-9567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1152533225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist