Provider Demographics
NPI:1821190612
Name:GULLICKSON, SUSAN M (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:GULLICKSON
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:PO BOX 2427
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-1089
Mailing Address - Country:US
Mailing Address - Phone:815-834-2400
Mailing Address - Fax:815-834-2424
Practice Address - Street 1:9634 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3391
Practice Address - Country:US
Practice Address - Phone:708-423-4800
Practice Address - Fax:708-423-4843
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCJ4383OtherR.R. MEDICARE GROUP #
IL1623066OtherBCBS PROVIDER #
ILCJ4383OtherR.R. MEDICARE GROUP #