Provider Demographics
NPI:1699081471
Name:RUCK, SUSAN (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:RUCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:RUCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTPC
Mailing Address - Street 1:5 RUSSELL CT
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3522
Mailing Address - Country:US
Mailing Address - Phone:631-258-6612
Mailing Address - Fax:631-757-0811
Practice Address - Street 1:5 RUSSELL CT
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3522
Practice Address - Country:US
Practice Address - Phone:631-258-6612
Practice Address - Fax:631-757-0811
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003115-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics