Provider Demographics
NPI:1134166267
Name:SMITH, SUSAN M (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:OTTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:285 FOREST GROVE DR STE 208
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3738
Mailing Address - Country:US
Mailing Address - Phone:262-799-4090
Mailing Address - Fax:262-799-4093
Practice Address - Street 1:285 FOREST GROVE DR STE 208
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3738
Practice Address - Country:US
Practice Address - Phone:262-799-4090
Practice Address - Fax:262-799-4093
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3476-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40445500Medicaid