Provider Demographics
NPI:1063897858
Name:VANWALKER, SUSAN ARLENE (ITDS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ARLENE
Last Name:VANWALKER
Suffix:
Gender:F
Credentials:ITDS
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ARLENE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5568 WEST KEATING COURT
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34448-1667
Mailing Address - Country:US
Mailing Address - Phone:813-403-1411
Mailing Address - Fax:
Practice Address - Street 1:315 NE 10TH AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-4456
Practice Address - Country:US
Practice Address - Phone:813-403-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist