Provider Demographics
NPI:1417560459
Name:CARBINE, SUSAN CAROL (PTA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAROL
Last Name:CARBINE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 KNAPPS HWY
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-4210
Mailing Address - Country:US
Mailing Address - Phone:203-524-2440
Mailing Address - Fax:
Practice Address - Street 1:226 MILL HILL AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2826
Practice Address - Country:US
Practice Address - Phone:203-384-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001726208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation