Provider Demographics
NPI:1194901900
Name:THORSON, SUZANNE (PT)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:THORSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84335-0123
Mailing Address - Country:US
Mailing Address - Phone:435-757-6220
Mailing Address - Fax:
Practice Address - Street 1:140 N MAIN ST
Practice Address - Street 2:BOX 123
Practice Address - City:SMITHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84335-1908
Practice Address - Country:US
Practice Address - Phone:435-757-6220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-11
Last Update Date:2010-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT122137-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1194901900OtherEDUCATORS
UT627706OtherDMBA
UT335326OtherALTIUS
UT59796OtherPEHP
UT71086946184335A002OtherTRIWEST
UT71086946184335A002OtherTRIWEST
UT005715001Medicare PIN