Healthcare Provider Details

I. General information

NPI: 1689940777
Provider Name (Legal Business Name): SUSAN ANTRIM PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN ROEPKE PTA

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 EVANS AVE
VALPARAISO IN
46383-6940
US

IV. Provider business mailing address

601 POST ST
WANATAH IN
46390-9581
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-9621
  • Fax:
Mailing address:
  • Phone: 708-257-7893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number160.005856
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06004960A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: