Provider Demographics
NPI:1912270588
Name:SUDERMAN, ELIZABETH A (MOT, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:A
Last Name:SUDERMAN
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:MRS
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:SAMUELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:1335 E 42ND PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-4048
Mailing Address - Country:US
Mailing Address - Phone:317-223-1694
Mailing Address - Fax:
Practice Address - Street 1:7030 S YALE AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-5712
Practice Address - Country:US
Practice Address - Phone:918-497-1068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1697225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist