Provider Demographics
NPI:1760999007
Name:DETWILER, SUSAN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:DETWILER
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 S 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-5540
Mailing Address - Country:US
Mailing Address - Phone:956-655-1052
Mailing Address - Fax:
Practice Address - Street 1:2600 E WISCONSIN RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78542-6586
Practice Address - Country:US
Practice Address - Phone:956-289-2402
Practice Address - Fax:956-289-2402
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT18872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer