Healthcare Provider Details

I. General information

NPI: 1154661072
Provider Name (Legal Business Name): SUSAN KOPLIN OVERMILLER RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2013
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ASSOCIATION DR NORTHGATE BUSINESS PARK
CHARLESTON WV
25311-1272
US

IV. Provider business mailing address

306 PINE CREST LN
RIPLEY WV
25271-1631
US

V. Phone/Fax

Practice location:
  • Phone: 304-343-6600
  • Fax:
Mailing address:
  • Phone: 304-237-1565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 001269
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: