Provider Demographics
NPI:1063892263
Name:SUSA, ALLISON (ATC)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:SUSA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 DONAGHEY AVE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72035-5001
Mailing Address - Country:US
Mailing Address - Phone:715-937-2017
Mailing Address - Fax:
Practice Address - Street 1:2200 MEADOWLAKE RD
Practice Address - Street 2:APT. 1703
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-2578
Practice Address - Country:US
Practice Address - Phone:715-937-2017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer