Provider Demographics
NPI:1265578041
Name:LEWIS, SUZANNE ELIZABETH (PT)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:ELIZABETH
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:SUZANNE
Other - Middle Name:ELIZABETH
Other - Last Name:LINHARDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:341 SCHELLRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-1156
Mailing Address - Country:US
Mailing Address - Phone:573-635-8794
Mailing Address - Fax:
Practice Address - Street 1:1403 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-4253
Practice Address - Country:US
Practice Address - Phone:573-751-7142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002000493225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1114090792OtherGROUP NPI