Provider Demographics
NPI:1295745206
Name:WILLIAMS, SUSAN MARIE (PT)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POB 9270
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96162
Mailing Address - Country:US
Mailing Address - Phone:530-587-2356
Mailing Address - Fax:530-587-2356
Practice Address - Street 1:5990 SILVER LAKE RD,
Practice Address - Street 2:SUITE D
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89506
Practice Address - Country:US
Practice Address - Phone:775-337-8776
Practice Address - Fax:775-337-8778
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT79060225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ08443ZOtherBLUE SHIELD
CAZZZ22285ZMedicare ID - Type Unspecified