Provider Demographics
NPI:1740897941
Name:MCCOLLISTER, SUSAN T
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:T
Last Name:MCCOLLISTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 S STATE ROUTE 133
Mailing Address - Street 2:
Mailing Address - City:BLANCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45107-8483
Mailing Address - Country:US
Mailing Address - Phone:513-310-2075
Mailing Address - Fax:
Practice Address - Street 1:1520 S STATE ROUTE 133
Practice Address - Street 2:
Practice Address - City:BLANCHESTER
Practice Address - State:OH
Practice Address - Zip Code:45107-8483
Practice Address - Country:US
Practice Address - Phone:513-310-2075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376J00000X
OH347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
Yes376J00000XNursing Service Related ProvidersHomemaker