Provider Demographics
NPI:1245354646
Name:GAVIN, SUSAN ELIZABETH (PTA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:GAVIN
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 1:233 AQUIDNECK ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02744-1401
Mailing Address - Country:US
Mailing Address - Phone:508-994-5109
Mailing Address - Fax:
Practice Address - Street 1:495 NEW BOSTON RD
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-5835
Practice Address - Country:US
Practice Address - Phone:508-679-0109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3233225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant