=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538721089
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN A SALIBA PT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2019
-----------------------------------------------------
Last Update Date | 07/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 EMMET ST S
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22903-2455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-243-4033
-----------------------------------------------------
Fax | 434-924-1389
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 400407
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22904-4407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-243-4033
-----------------------------------------------------
Fax | 434-924-1389
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 0126000442
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2251S0007X
-----------------------------------------------------
Taxonomy Name | Sports Physical Therapist
-----------------------------------------------------
License Number | 2305003663
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------