Provider Demographics
NPI:1619019015
Name:MIZE, SUSAN DIANE (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:MIZE
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 1:3124 QUIMBY RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7043
Mailing Address - Country:US
Mailing Address - Phone:757-641-0545
Mailing Address - Fax:
Practice Address - Street 1:3124 QUIMBY RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7043
Practice Address - Country:US
Practice Address - Phone:757-641-0545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305002648225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist