Provider Demographics
NPI:1962580308
Name:ACKROYD, SUSANNE MARIE (PT)
Entity type:Individual
Prefix:
First Name:SUSANNE
Middle Name:MARIE
Last Name:ACKROYD
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 1:996 OLYMPUS PARK DRIVE
Mailing Address - Street 2:D203
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117
Mailing Address - Country:US
Mailing Address - Phone:801-815-4920
Mailing Address - Fax:
Practice Address - Street 1:451 BISHOP FEDERAL LANE
Practice Address - Street 2:ST JOSEPHS VILLA
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115
Practice Address - Country:US
Practice Address - Phone:801-487-7557
Practice Address - Fax:801-468-6843
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT50367062401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD6333Medicaid