Provider Demographics
NPI:1306933163
Name:PETALUMA PHYSICAL THERAPY ASSOCIATES INC
Entity type:Organization
Organization Name:PETALUMA PHYSICAL THERAPY ASSOCIATES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:SUSICK
Authorized Official - Suffix:
Authorized Official - Credentials:MS PT ATC
Authorized Official - Phone:707-763-0115
Mailing Address - Street 1:169 LYNCH CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-2344
Mailing Address - Country:US
Mailing Address - Phone:707-763-0115
Mailing Address - Fax:707-763-2130
Practice Address - Street 1:169 LYNCH CREEK WAY
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-2344
Practice Address - Country:US
Practice Address - Phone:707-763-0115
Practice Address - Fax:707-763-2130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 11310225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ17644ZMedicare UPIN