Provider Demographics
NPI:1548387541
Name:VICK, SUSAN C (OTRL)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:VICK
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:COPELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 69030
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-9030
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:1580 ARMORY DR STE B
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851-2470
Practice Address - Country:US
Practice Address - Phone:757-562-0990
Practice Address - Fax:757-562-0496
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119000324225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1548387541Medicaid
VAC10066OtherMEDICARE PTAN
VA1043237936Medicaid
VAC05954Medicare PIN