Provider Demographics
NPI:1467676692
Name:JUSTICE, SUSAN KEITH (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KEITH
Last Name:JUSTICE
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 921
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-0921
Mailing Address - Country:US
Mailing Address - Phone:770-943-7979
Mailing Address - Fax:770-943-7161
Practice Address - Street 1:2001 CHURCH DR
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-4720
Practice Address - Country:US
Practice Address - Phone:770-943-7979
Practice Address - Fax:770-943-7161
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0080452251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics