Provider Demographics
NPI:1285782839
Name:BATES, SUSAN W (RPT)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:W
Last Name:BATES
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:MRS
Other - First Name:ANITA
Other - Middle Name:SUSAN
Other - Last Name:BATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT
Mailing Address - Street 1:12751 HIGHWAY 491 S
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:MS
Mailing Address - Zip Code:39365-8546
Mailing Address - Country:US
Mailing Address - Phone:601-656-6827
Mailing Address - Fax:
Practice Address - Street 1:711 AVIGNON DR
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5120
Practice Address - Country:US
Practice Address - Phone:601-605-6777
Practice Address - Fax:601-605-8869
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0886225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist