Provider Demographics
NPI:1609031061
Name:MAXWELL, SUSAN (DPT)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:BAUMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:8561 S VENTANA DR
Mailing Address - Street 2:APT 4517
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-8343
Mailing Address - Country:US
Mailing Address - Phone:414-861-1202
Mailing Address - Fax:
Practice Address - Street 1:7610 PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4318
Practice Address - Country:US
Practice Address - Phone:262-948-3600
Practice Address - Fax:262-948-3690
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11618-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist