Provider Demographics
NPI:1700209822
Name:MOORTHY, SUSITA (PT)
Entity Type:Individual
Prefix:
First Name:SUSITA
Middle Name:
Last Name:MOORTHY
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 1:11765 SKYLARK RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-9370
Mailing Address - Country:US
Mailing Address - Phone:301-519-9267
Mailing Address - Fax:
Practice Address - Street 1:11765 SKYLARK RD
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:MD
Practice Address - Zip Code:20871-9370
Practice Address - Country:US
Practice Address - Phone:301-519-9267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-24
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22748225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD373775Medicare PIN