Provider Demographics
NPI:1952652224
Name:SMITH, SUSAN (DPT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 LANDMARK DR
Mailing Address - Street 2:SUITE E3
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2160
Mailing Address - Country:US
Mailing Address - Phone:850-529-6906
Mailing Address - Fax:309-863-5923
Practice Address - Street 1:211 LANDMARK DR
Practice Address - Street 2:SUITE E3
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2160
Practice Address - Country:US
Practice Address - Phone:850-529-6906
Practice Address - Fax:309-863-5923
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL07005408225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist