Provider Demographics
NPI:1982765137
Name:PRUST, SUSAN ELIZABETH (PT DIP MDT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:PRUST
Suffix:
Gender:F
Credentials:PT DIP MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 N HUNT CLUB RD
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-2656
Mailing Address - Country:US
Mailing Address - Phone:847-855-2890
Mailing Address - Fax:847-855-2147
Practice Address - Street 1:1405 N HUNT CLUB RD
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-2656
Practice Address - Country:US
Practice Address - Phone:847-855-2890
Practice Address - Fax:847-855-2147
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070 006024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist