Provider Demographics
NPI:1891244893
Name:AUSTIN, SUSAN (PTA, CDP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:PTA, CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12630 PONY EXPRESS DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-4410
Mailing Address - Country:US
Mailing Address - Phone:865-686-2968
Mailing Address - Fax:
Practice Address - Street 1:300 LABORATORY RD
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6911
Practice Address - Country:US
Practice Address - Phone:865-482-7698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-02
Last Update Date:2016-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2880225200000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility