Provider Demographics
NPI:1154794659
Name:POWROZNIK, SUSAN M (PT, DPT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:POWROZNIK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 BOULDERS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-560-5595
Mailing Address - Fax:804-560-9029
Practice Address - Street 1:4710 PUDDLEDOCK RD STE 100
Practice Address - Street 2:
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875-1269
Practice Address - Country:US
Practice Address - Phone:804-732-0035
Practice Address - Fax:804-287-2786
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1300752225100000X
CO0016104225100000X
HI4738225100000X
VA2305209951225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherMEDICARE GROUP PTAN
VA1154794659OtherMEDICAID QMB PROVIDER ID
VAQ52041AMedicare PIN