Provider Demographics
NPI:1912960055
Name:SKINNER, SUZIE JEFFERIS (MPT)
Entity type:Individual
Prefix:MRS
First Name:SUZIE
Middle Name:JEFFERIS
Last Name:SKINNER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421718
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-4203
Mailing Address - Country:US
Mailing Address - Phone:843-652-8226
Mailing Address - Fax:
Practice Address - Street 1:2200 CROW LN STE 201
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-1663
Practice Address - Country:US
Practice Address - Phone:843-727-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202321225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010333814Medicaid
P00337585OtherMEDICARE RAILROAD
VA7801800OtherAETNA
VA193615OtherANTHEM
VA193617OtherANTHEM
VA7801800OtherAETNA