Provider Demographics
NPI:1871566042
Name:PETTER, SUSAN M (PT)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:PETTER
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 1:1221 WICKFORD DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-2127
Mailing Address - Country:US
Mailing Address - Phone:217-793-3762
Mailing Address - Fax:217-793-3762
Practice Address - Street 1:1221 WICKFORD DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-2127
Practice Address - Country:US
Practice Address - Phone:217-793-3762
Practice Address - Fax:217-793-3762
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics