Provider Demographics
NPI:1992074579
Name:TEUBNER, SUSAN L (COTA)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:L
Last Name:TEUBNER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2703 BROKEN ARROW DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-3909
Mailing Address - Country:US
Mailing Address - Phone:352-978-6772
Mailing Address - Fax:
Practice Address - Street 1:2703 BROKEN ARROW
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825
Practice Address - Country:US
Practice Address - Phone:352-978-6772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002099A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant