Provider Demographics
NPI:1679040232
Name:CLOSE, SUE ELLEN
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:ELLEN
Last Name:CLOSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1653 MOORESVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37091-1413
Mailing Address - Country:US
Mailing Address - Phone:931-359-4506
Mailing Address - Fax:931-359-8139
Practice Address - Street 1:1653 MOORESVILLE HWY
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:TN
Practice Address - Zip Code:37091-1413
Practice Address - Country:US
Practice Address - Phone:931-359-4506
Practice Address - Fax:931-359-8139
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN489208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN489OtherPHYSICAL THERPIST ASSISTANT