Provider Demographics
NPI:1518399476
Name:WADSWORTH, SUSAN SMICKLAS (OT)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:SMICKLAS
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 MARSH COVE CT
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-1645
Mailing Address - Country:US
Mailing Address - Phone:904-962-1299
Mailing Address - Fax:
Practice Address - Street 1:1002 MARSH COVE CT
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-1645
Practice Address - Country:US
Practice Address - Phone:904-962-1299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT8659225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist