Provider Demographics
NPI:1669188801
Name:FISKE, SUSAN ANN (PTA)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ANN
Last Name:FISKE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 ORCHARD AVE APT B
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-4100
Mailing Address - Country:US
Mailing Address - Phone:401-919-4615
Mailing Address - Fax:
Practice Address - Street 1:59 SUMMER ST
Practice Address - Street 2:
Practice Address - City:REHOBOTH
Practice Address - State:MA
Practice Address - Zip Code:02769-2221
Practice Address - Country:US
Practice Address - Phone:508-252-5814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA721225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty