Provider Demographics
NPI:1639333768
Name:SULLIVAN, SUSAN CLAIRE (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CLAIRE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:CLAIRE
Other - Last Name:RIESENBECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5754 BRIDGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45248-3100
Mailing Address - Country:US
Mailing Address - Phone:513-661-6555
Mailing Address - Fax:513-661-6556
Practice Address - Street 1:5754 BRIDGETOWN RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45248-3100
Practice Address - Country:US
Practice Address - Phone:513-661-6555
Practice Address - Fax:513-661-6556
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH006299225100000X
KY4018225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4018OtherKENTUCKY LICENSE
OH006299OtherOHIO LICENSE