Healthcare Provider Details

I. General information

NPI: 1477921906
Provider Name (Legal Business Name): SUSAN WARD KOSKO DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 W JACKSON ST
RIDGELAND MS
39157-2355
US

IV. Provider business mailing address

246 LAKE CIR
MADISON MS
39110-6303
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-0859
  • Fax:
Mailing address:
  • Phone: 865-300-5149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTH7184
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPTH7184
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: