Provider Demographics
NPI:1528213451
Name:BLACK, SUSAN ANN (OTR/L)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANN
Last Name:BLACK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:SHIRKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16063 SERENITY POINT LN
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-8610
Mailing Address - Country:US
Mailing Address - Phone:847-287-5109
Mailing Address - Fax:
Practice Address - Street 1:4408 W WALNUT ST
Practice Address - Street 2:APT/SUITE
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-9526
Practice Address - Country:US
Practice Address - Phone:479-246-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-19
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist