Provider Demographics
NPI:1831464114
Name:PHILLIPS, SUSAN M (LMT)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LMT
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 241
Mailing Address - Street 2:
Mailing Address - City:SOUTH OTSELIC
Mailing Address - State:NY
Mailing Address - Zip Code:13155-0241
Mailing Address - Country:US
Mailing Address - Phone:315-653-7519
Mailing Address - Fax:315-653-7848
Practice Address - Street 1:DERUYTER RD
Practice Address - Street 2:
Practice Address - City:SOUTH OTSELIC
Practice Address - State:NY
Practice Address - Zip Code:13155-0241
Practice Address - Country:US
Practice Address - Phone:315-653-7519
Practice Address - Fax:315-653-7848
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013143225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist