Provider Demographics
NPI:1295775955
Name:COOK, SUSAN GERALD (PT)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:GERALD
Last Name:COOK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 OLD MILL TRCE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30656-4379
Mailing Address - Country:US
Mailing Address - Phone:770-207-6390
Mailing Address - Fax:678-374-4855
Practice Address - Street 1:1045 OLD MILL TRCE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30656-4379
Practice Address - Country:US
Practice Address - Phone:770-207-6390
Practice Address - Fax:678-374-4855
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5588225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000875102BMedicaid