Basic Information
| Provider Information | |||||||||
| NPI: | 1003099649 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRACE | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 260 FORT SANDERS WEST BLVD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655584491 | ||||||||
| FaxNumber: | 8655584493 | ||||||||
| Practice Location | |||||||||
| Address1: | 260 FORT SANDERS WEST BLVD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655584491 | ||||||||
| FaxNumber: | 8655584493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2007 | ||||||||
| LastUpdateDate: | 10/20/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5564 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 5233 | SC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 10851 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00747042 | 01 | RAILROAD MEDICARE | OTHER | 4223417 | 01 | TN | BLUECROSS BLUESHIELD | OTHER | 1512782 | 05 | TN | MEDICAID |