Healthcare Provider Details

I. General information

NPI: 1003039660
Provider Name (Legal Business Name): SUSANA CHACON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 GRANT AVE
NORTH AUGUSTA SC
29841-3632
US

IV. Provider business mailing address

516 GRANT AVE
NORTH AUGUSTA SC
29841-3632
US

V. Phone/Fax

Practice location:
  • Phone: 706-825-2996
  • Fax: 855-232-8604
Mailing address:
  • Phone: 706-825-2996
  • Fax: 855-232-8604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT001387
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: