Provider Demographics
NPI:1174243430
Name:UPCHURCH, SUSAN (MT-BC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:UPCHURCH
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3704
Mailing Address - Country:US
Mailing Address - Phone:812-288-1156
Mailing Address - Fax:
Practice Address - Street 1:20 MEDICAL VILLAGE DR STE 200
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-5403
Practice Address - Country:US
Practice Address - Phone:859-202-0407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2024-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
15349225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist