Provider Demographics
NPI:1568659290
Name:PROVOST-DANNER, SUSAN M (OTR)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:PROVOST-DANNER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8621 MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:SALADO
Mailing Address - State:TX
Mailing Address - Zip Code:76571-5109
Mailing Address - Country:US
Mailing Address - Phone:254-947-5431
Mailing Address - Fax:
Practice Address - Street 1:1102 WINKLER AVE
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-6249
Practice Address - Country:US
Practice Address - Phone:254-634-8505
Practice Address - Fax:254-519-3477
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004598225X00000X
TX106402225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist