Healthcare Provider Details

I. General information

NPI: 1679621767
Provider Name (Legal Business Name): SUSAN WORTHINGTON P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 COUNTY RD. 179
OJO CALIENTE NM
87549
US

IV. Provider business mailing address

PO BOX 88 5 COUNTY RD. 179
OJO CALIENTE NM
87549-0088
US

V. Phone/Fax

Practice location:
  • Phone: 505-927-1101
  • Fax:
Mailing address:
  • Phone: 505-927-1101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1566
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: