Healthcare Provider Details

I. General information

NPI: 1639295199
Provider Name (Legal Business Name): SUSAN HAYES A.T.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 UNION ST
VALPARAISO IN
46383-4529
US

IV. Provider business mailing address

2700 DOUBLE EAGLE LN APT A
VALPARAISO IN
46383-2865
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-5236
  • Fax: 219-464-6879
Mailing address:
  • Phone: 219-464-5236
  • Fax: 219-464-6879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000083A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: