Provider Demographics
NPI:1104029255
Name:THOM, SUSANNE ELIZABETH (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MS
First Name:SUSANNE
Middle Name:ELIZABETH
Last Name:THOM
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
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Mailing Address - Street 1:1522 EUCLID STREET
Mailing Address - Street 2:#19
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404
Mailing Address - Country:US
Mailing Address - Phone:310-576-6030
Mailing Address - Fax:310-453-3373
Practice Address - Street 1:1450 CLOVERFIELD ROAD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-828-6584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA14858225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT14859AMedicare ID - Type Unspecified