Provider Demographics
NPI:1427108794
Name:BURTCH, SUSAN MARIE (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:BURTCH
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 1:3503 N 80TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-9752
Mailing Address - Country:US
Mailing Address - Phone:715-675-4415
Mailing Address - Fax:
Practice Address - Street 1:520 N 32ND AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4701
Practice Address - Country:US
Practice Address - Phone:715-847-2600
Practice Address - Fax:715-847-2606
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2445-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40343300Medicaid