Provider Demographics
NPI:1174692727
Name:SUSSEN, GRETCHEN ANN (PTA)
Entity type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:ANN
Last Name:SUSSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2789 MCMINNVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-3618
Mailing Address - Country:US
Mailing Address - Phone:615-653-6275
Mailing Address - Fax:
Practice Address - Street 1:585 INTERSTATE DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-3190
Practice Address - Country:US
Practice Address - Phone:931-723-7156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3332225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN446631Medicare ID - Type UnspecifiedGROUP NUMBER