Provider Demographics
NPI:1730141409
Name:STOVALL, SUSAN GOLDENBERG (PT)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:GOLDENBERG
Last Name:STOVALL
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 1:210 S BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-5402
Mailing Address - Country:US
Mailing Address - Phone:910-692-8269
Mailing Address - Fax:910-692-8479
Practice Address - Street 1:210 S BENNETT ST
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-5402
Practice Address - Country:US
Practice Address - Phone:910-692-8269
Practice Address - Fax:910-692-8479
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2089225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0775ROtherBLUE CROSS BLUE SHIELD
NC0775ROtherBLUE CROSS BLUE SHIELD
NC650019379Medicare ID - Type UnspecifiedRAILROAD