Provider Demographics
NPI:1902854656
Name:SMITH, SUSAN A (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:SMITH
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 1:3642 NEREIS DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-8013
Mailing Address - Country:US
Mailing Address - Phone:619-741-7800
Mailing Address - Fax:
Practice Address - Street 1:34520 BOB WILSON DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-2098
Practice Address - Country:US
Practice Address - Phone:619-532-5466
Practice Address - Fax:619-532-6908
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 232892251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics