Provider Demographics
NPI:1902079361
Name:NORTH, SUSAN K (PTA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:NORTH
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 1:263 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:WI
Mailing Address - Zip Code:53956-1409
Mailing Address - Country:US
Mailing Address - Phone:920-326-5691
Mailing Address - Fax:
Practice Address - Street 1:263 CENTER ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:WI
Practice Address - Zip Code:53956-1409
Practice Address - Country:US
Practice Address - Phone:920-326-5691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI497-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant