Basic Information
| Provider Information | |||||||||
| NPI: | 1235208190 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASTANO | ||||||||
| FirstName: | SUZANNE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 518 | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706318277 | ||||||||
| FaxNumber: | 7706319403 | ||||||||
| Practice Location | |||||||||
| Address1: | 10090 MEDLOCK BRIDGE RD | ||||||||
| Address2: | SUITE100 | ||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300974428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708135575 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | PT006721 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT006721 | 01 | GA | STATE LISC NUMBER | OTHER |