Provider Demographics
NPI:1649431271
Name:MYRICK, SUSAN JEAN (COTAL)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:JEAN
Last Name:MYRICK
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 UNDERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653
Mailing Address - Country:US
Mailing Address - Phone:256-332-3826
Mailing Address - Fax:256-332-3874
Practice Address - Street 1:390 UNDERWOOD RD
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653
Practice Address - Country:US
Practice Address - Phone:256-332-3826
Practice Address - Fax:256-332-3874
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1313224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant