Provider Demographics
NPI:1477686525
Name:MCCOLL, SUSAN G (DC)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:G
Last Name:MCCOLL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 MAIN ST
Mailing Address - Street 2:UNIT 507
Mailing Address - City:DEEP RIVER
Mailing Address - State:CT
Mailing Address - Zip Code:06417-2052
Mailing Address - Country:US
Mailing Address - Phone:203-640-2529
Mailing Address - Fax:
Practice Address - Street 1:1609 ROUTE 154
Practice Address - Street 2:
Practice Address - City:HADDAM
Practice Address - State:CT
Practice Address - Zip Code:06438
Practice Address - Country:US
Practice Address - Phone:860-345-5121
Practice Address - Fax:860-345-8262
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000678111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT350000859Medicare ID - Type Unspecified
CT22604Medicare UPIN