Healthcare Provider Details

I. General information

NPI: 1689719577
Provider Name (Legal Business Name): SUSAN C MILLISON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 CLOUD DANCE
SANTA FE NM
87507-2591
US

IV. Provider business mailing address

PO BOX 517
ARROYO HONDO NM
87513-0517
US

V. Phone/Fax

Practice location:
  • Phone: 505-438-2960
  • Fax: 505-438-2960
Mailing address:
  • Phone: 505-776-1213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1977
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: