Provider Demographics
NPI:1952425837
Name:MORT, SUSAN KAY (DC)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:KAY
Last Name:MORT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 S FIRST ST
Mailing Address - Street 2:
Mailing Address - City:PIERCETON
Mailing Address - State:IN
Mailing Address - Zip Code:46562-9200
Mailing Address - Country:US
Mailing Address - Phone:574-594-2711
Mailing Address - Fax:
Practice Address - Street 1:526 S FIRST ST
Practice Address - Street 2:
Practice Address - City:PIERCETON
Practice Address - State:IN
Practice Address - Zip Code:46562-9200
Practice Address - Country:US
Practice Address - Phone:574-594-2711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-18
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN969111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN257280Medicare UPIN