Provider Demographics
NPI:1962599704
Name:SUSICK, RICK (MS PT ATC)
Entity type:Individual
Prefix:
First Name:RICK
Middle Name:
Last Name:SUSICK
Suffix:
Gender:M
Credentials:MS PT ATC
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Mailing Address - Street 1:312 SHERRI CT
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-4839
Mailing Address - Country:US
Mailing Address - Phone:707-765-6392
Mailing Address - Fax:707-769-8597
Practice Address - Street 1:169 LYNCH CREEK WAY
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-2344
Practice Address - Country:US
Practice Address - Phone:707-763-0115
Practice Address - Fax:707-763-2130
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPT11310225100000X, 2251S0007X
CAPT 113102251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 11310OtherLICENSE
CA781081OtherATHLETIC TRAINER CERTI.
CAPT 11310OtherLICENSE