Provider Demographics
NPI:1821777012
Name:SUSI, KIMBERLEE DAE (PTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:DAE
Last Name:SUSI
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 SWEDEN ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CARIBOU
Mailing Address - State:ME
Mailing Address - Zip Code:04736-2101
Mailing Address - Country:US
Mailing Address - Phone:207-551-0229
Mailing Address - Fax:
Practice Address - Street 1:163 VAN BUREN RD STE 1
Practice Address - Street 2:
Practice Address - City:CARIBOU
Practice Address - State:ME
Practice Address - Zip Code:04736-3588
Practice Address - Country:US
Practice Address - Phone:207-498-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA6572225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant