Provider Demographics
NPI:1861558942
Name:SMITH, SUSAN
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 OPING RD
Mailing Address - Street 2:
Mailing Address - City:POMPTON PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07444-1417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 CHANGEBRIDGE RD
Practice Address - Street 2:SUITE A5
Practice Address - City:MONTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07045-9115
Practice Address - Country:US
Practice Address - Phone:973-575-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00265800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA00265800OtherLICENSE #