Provider Demographics
NPI:1962464917
Name:EARL, SUSAN E (MPT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:EARL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:SUEB
Other - Middle Name:
Other - Last Name:MEDSKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:555 RIVERGATE STE B1-108
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7473
Mailing Address - Country:US
Mailing Address - Phone:970-426-9074
Mailing Address - Fax:
Practice Address - Street 1:555 RIVERGATE STE B1-108
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7473
Practice Address - Country:US
Practice Address - Phone:970-426-9074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0004785225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07609060Medicaid
COQ20914Medicare UPIN
COC543218Medicare PIN