Healthcare Provider Details

I. General information

NPI: 1790903284
Provider Name (Legal Business Name): SUSAN THERESE CHARLWOOD PT, MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN THERESE BALKUN PT

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 DANIELSON PIKE SUITE D
NORTH SCITUATE RI
02857-1802
US

IV. Provider business mailing address

58 E KILLINGLY RD
FOSTER RI
02825-1428
US

V. Phone/Fax

Practice location:
  • Phone: 401-647-4455
  • Fax: 401-647-4456
Mailing address:
  • Phone: 401-647-2975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00157
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1602
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: