Provider Demographics
NPI:1699736330
Name:PHILLIPS, SUSAN RAND (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:RAND
Last Name:PHILLIPS
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 1:18A HIGH ST
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:ME
Mailing Address - Zip Code:04364
Mailing Address - Country:US
Mailing Address - Phone:207-377-9400
Mailing Address - Fax:207-377-3385
Practice Address - Street 1:18A HIGH ST
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:ME
Practice Address - Zip Code:04364
Practice Address - Country:US
Practice Address - Phone:207-377-9400
Practice Address - Fax:207-377-3385
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT9400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME004625OtherBC/BS
ME123230000Medicaid
ME123230000Medicaid