Provider Demographics
NPI:1477627636
Name:WALDO, SUSAN (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WALDO
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 1:20099 ASHBROOK PL
Mailing Address - Street 2:UNIT 195
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-3367
Mailing Address - Country:US
Mailing Address - Phone:703-726-9866
Mailing Address - Fax:703-726-9868
Practice Address - Street 1:20099 ASHBROOK PL
Practice Address - Street 2:UNIT 195
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-3367
Practice Address - Country:US
Practice Address - Phone:703-726-9866
Practice Address - Fax:703-726-9868
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305004524OtherSTATE LICENSE