Provider Demographics
NPI:1730714650
Name:LICK, SUSAN MARIE (OTR/L)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:LICK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13807 W 165TH AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:IN
Mailing Address - Zip Code:46356-9337
Mailing Address - Country:US
Mailing Address - Phone:219-951-6161
Mailing Address - Fax:
Practice Address - Street 1:6100 MILLER AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46403-2469
Practice Address - Country:US
Practice Address - Phone:219-427-0196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004027A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist