Healthcare Provider Details

I. General information

NPI: 1700851227
Provider Name (Legal Business Name): SUSAN M PENCILLE P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 COFIELD RD
MARTINEZ GA
30907-1698
US

IV. Provider business mailing address

166 COFIELD RD
MARTINEZ GA
30907-1698
US

V. Phone/Fax

Practice location:
  • Phone: 706-267-9225
  • Fax:
Mailing address:
  • Phone: 706-267-9225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number002033
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: