Provider Demographics
NPI:1699818591
Name:BLAIR, SUSAN (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BLAIR
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 1:2924 BROOK RD
Mailing Address - Street 2:CHILDREN'S HOSPITAL CREDENTIALING DEPT
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-1215
Mailing Address - Country:US
Mailing Address - Phone:804-321-7474
Mailing Address - Fax:804-321-2728
Practice Address - Street 1:2924 BROOK RD
Practice Address - Street 2:CHILDREN'S HOSPITAL CREDENTIALING DEPT
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-1215
Practice Address - Country:US
Practice Address - Phone:804-321-7474
Practice Address - Fax:804-321-2728
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004605225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008953261Medicaid