Provider Demographics
NPI:1639479876
Name:TUCKER, SUSAN J (P T)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:TUCKER
Suffix:
Gender:F
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6806 W 83RD ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66204-3956
Mailing Address - Country:US
Mailing Address - Phone:913-825-9827
Mailing Address - Fax:
Practice Address - Street 1:8335 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-1915
Practice Address - Country:US
Practice Address - Phone:913-642-3160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-00784225100000X
MORO451225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist