Provider Demographics
NPI:1134166267
Name:SMITH, SUSAN M (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:OTTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:17045 W. CAPITOL DR.
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005
Mailing Address - Country:US
Mailing Address - Phone:262-790-5775
Mailing Address - Fax:262-790-5710
Practice Address - Street 1:17045 W. CAPITOL DR.
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005
Practice Address - Country:US
Practice Address - Phone:262-790-5775
Practice Address - Fax:262-790-5710
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3476024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40445500Medicaid