Provider Demographics
NPI:1386979599
Name:LACKNER, SUSAN IRENE (PT)
Entity type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:IRENE
Last Name:LACKNER
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 1:10753 FALLS RD
Mailing Address - Street 2:SUITE 235
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4535
Mailing Address - Country:US
Mailing Address - Phone:410-583-2665
Mailing Address - Fax:410-847-3838
Practice Address - Street 1:10753 FALLS RD
Practice Address - Street 2:SUITE 235
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4535
Practice Address - Country:US
Practice Address - Phone:410-583-2665
Practice Address - Fax:410-847-3838
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22186225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist