Basic Information
Provider Information | |||||||||
NPI: | 1548387541 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VICK | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTRL | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | COPELAND | ||||||||
OtherFirstName: | SUSAN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 69030 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212649030 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7578732302 | ||||||||
FaxNumber: | 7578732306 | ||||||||
Practice Location | |||||||||
Address1: | 1580 ARMORY DR STE B | ||||||||
Address2: |   | ||||||||
City: | FRANKLIN | ||||||||
State: | VA | ||||||||
PostalCode: | 238512470 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7575620990 | ||||||||
FaxNumber: | 7575620496 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/23/2007 | ||||||||
LastUpdateDate: | 05/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 0119000324 | VA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 1548387541 | 05 | VA |   | MEDICAID | C10066 | 01 | VA | MEDICARE PTAN | OTHER | 1043237936 | 05 | VA |   | MEDICAID |