Provider Demographics
NPI:1194490938
Name:TRIMBLE, SUSAN DIANE (LPTA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:TRIMBLE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 SPRING PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-6491
Mailing Address - Country:US
Mailing Address - Phone:314-606-2525
Mailing Address - Fax:
Practice Address - Street 1:15822 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2212
Practice Address - Country:US
Practice Address - Phone:636-220-1681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116757225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant