Provider Demographics
NPI:1952663551
Name:CONLON, SUSAN MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:CONLON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 DEANE BLVD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-3416
Mailing Address - Country:US
Mailing Address - Phone:262-515-2354
Mailing Address - Fax:
Practice Address - Street 1:3415 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-1924
Practice Address - Country:US
Practice Address - Phone:262-653-2951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1607-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant