Provider Demographics
NPI:1356436596
Name:SMITH, SUSAN STACY (DPT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:STACY
Last Name:SMITH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 W BENSON ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-4313
Mailing Address - Country:US
Mailing Address - Phone:404-877-8933
Mailing Address - Fax:
Practice Address - Street 1:1370 MONTREAL RD
Practice Address - Street 2:STE 100
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-8128
Practice Address - Country:US
Practice Address - Phone:770-939-3566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008759225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist