Provider Demographics
NPI:1336210046
Name:DORMA, SUZANNE ELIZABETH (PT)
Entity Type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:ELIZABETH
Last Name:DORMA
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 1:560 S LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3405
Mailing Address - Country:US
Mailing Address - Phone:859-301-2663
Mailing Address - Fax:859-301-0655
Practice Address - Street 1:2626 ALEXANDRIA PIKE STE 100
Practice Address - Street 2:
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:KY
Practice Address - Zip Code:41076-1530
Practice Address - Country:US
Practice Address - Phone:859-301-2663
Practice Address - Fax:859-817-7848
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT009735225100000X
KY004145225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100287900Medicaid
PT09735Medicare UPIN
KYK122580Medicare PIN