=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194019364
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSANNE LYNN NOVOTNY LMT, CDA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2011
-----------------------------------------------------
Last Update Date | 06/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2126 CRYSTAL DOWNS DR
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-8666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-389-6692
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2126 CRYSTAL DOWNS DR
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-8666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-389-6692
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172M00000X
-----------------------------------------------------
Taxonomy Name | Mechanotherapist
-----------------------------------------------------
License Number | MT112219
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT112219
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------