Provider Demographics
NPI:1558698571
Name:SHEA, SUSAN OKORN (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:OKORN
Last Name:SHEA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 ROUTE 111
Mailing Address - Street 2:SUITE 107
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-4370
Mailing Address - Country:US
Mailing Address - Phone:631-724-9509
Mailing Address - Fax:631-724-9549
Practice Address - Street 1:521 ROUTE 111
Practice Address - Street 2:SUITE 107
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-4370
Practice Address - Country:US
Practice Address - Phone:631-724-9509
Practice Address - Fax:631-724-9549
Is Sole Proprietor?:No
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10864225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist