=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912061441
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN JORALEMON HOUT PT, MED
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3343 N WINDSONG DR STE 5
-----------------------------------------------------
City | PRESCOTT VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86314-1213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-759-5591
-----------------------------------------------------
Fax | 928-759-5593
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1740 VALLEY RANCH CIR
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86303-6335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-708-0841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number | 3866
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------