Provider Demographics
NPI:1609080811
Name:SUSON, TIFFANY S (PT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:S
Last Name:SUSON
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 1:3 DUNCROFT PL
Mailing Address - Street 2:APT. TC
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-3181
Mailing Address - Country:US
Mailing Address - Phone:443-226-0265
Mailing Address - Fax:
Practice Address - Street 1:700 W 40TH ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2104
Practice Address - Country:US
Practice Address - Phone:410-235-8860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21801225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist