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General NPI Number Information
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NPI Number | 1306933163
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Entity Type | Organization
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Legal Business Name | PETALUMA PHYSICAL THERAPY ASSOCIATES INC
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Dates
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Enumeration Date | 10/05/2006
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Last Update Date | 03/18/2014
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Provider Practice Location Address
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Address Line | 169 LYNCH CREEK WAY
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City | PETALUMA
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State | CA
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Zip | 94954-2344
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Country | US
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Telephone | 707-763-0115
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Fax | 707-763-2130
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Provider Business Mailing Address
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Address Line | 169 LYNCH CREEK WAY
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City | PETALUMA
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State | CA
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Zip | 94954-2344
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Country | US
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Telephone | 707-763-0115
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Fax | 707-763-2130
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Authorized Official
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Title or Position | PRESIDENT
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Name | RICK SUSICK
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Credential | MS PT ATC
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Telephone | 707-763-0115
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT 11310
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License Number State | CA
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