Provider Demographics
NPI:1528031887
Name:RILEY, SUSANNA WATTS (PT)
Entity Type:Individual
Prefix:MRS
First Name:SUSANNA
Middle Name:WATTS
Last Name:RILEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:SUSANNA
Other - Middle Name:ROUTH
Other - Last Name:WATTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2018 GREYSTEM CIR
Mailing Address - Street 2:APARTMENT 301
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-9358
Mailing Address - Country:US
Mailing Address - Phone:970-497-2646
Mailing Address - Fax:
Practice Address - Street 1:17370 W GAGES LAKE RD
Practice Address - Street 2:
Practice Address - City:GAGES LAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-1831
Practice Address - Country:US
Practice Address - Phone:847-856-2773
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics