Provider Demographics
NPI:1851442990
Name:LANE, SUSAN MICHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MICHELLE
Last Name:LANE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MICHELLE
Other - Last Name:GOOD-POSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:PO BOX 2394
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74018-2394
Mailing Address - Country:US
Mailing Address - Phone:918-636-1234
Mailing Address - Fax:
Practice Address - Street 1:1202 N MUSKOGEE PL
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-3058
Practice Address - Country:US
Practice Address - Phone:918-342-6703
Practice Address - Fax:918-342-7889
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1270225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant