Provider Demographics
NPI:1902951098
Name:WHEELER, SUSAN CALLOWAY (PTDPTPCS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CALLOWAY
Last Name:WHEELER
Suffix:
Gender:F
Credentials:PTDPTPCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 STANLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKINGHAM
Mailing Address - State:NC
Mailing Address - Zip Code:28379-3034
Mailing Address - Country:US
Mailing Address - Phone:910-895-8174
Mailing Address - Fax:
Practice Address - Street 1:536 STANLEY AVE
Practice Address - Street 2:
Practice Address - City:ROCKINGHAM
Practice Address - State:NC
Practice Address - Zip Code:28379-3034
Practice Address - Country:US
Practice Address - Phone:910-895-8174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18982251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC079NHOtherBCBS IDENTIFICATION NUMBE
NC3403400Medicaid
NC562033116OtherTRICARE-TAX ID