Basic Information
| Provider Information | |||||||||
| NPI: | 1710227509 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORT | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 KUIVILA RD | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL FALLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499209675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9068753786 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5778 CHAPIN ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541219443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156963605 | ||||||||
| FaxNumber: | 7155284988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2013 | ||||||||
| LastUpdateDate: | 02/15/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 1458-19 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | 5502001869 | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.