Provider Demographics
NPI:1194045658
Name:MAACK, SUSAN (PTA)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:MAACK
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 1:4492 SUMMIT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-4477
Mailing Address - Country:US
Mailing Address - Phone:937-235-0490
Mailing Address - Fax:
Practice Address - Street 1:1390 KING TREE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-1401
Practice Address - Country:US
Practice Address - Phone:937-279-2711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5600225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant