Provider Demographics
NPI:1700851227
Name:PENCILLE, SUSAN M (PT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:PENCILLE
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 1:166 COFIELD RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-1698
Mailing Address - Country:US
Mailing Address - Phone:706-267-9225
Mailing Address - Fax:
Practice Address - Street 1:166 COFIELD RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-1698
Practice Address - Country:US
Practice Address - Phone:706-267-9225
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002033225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist