MEDICARE: MS. SUSAN MARIE OVERMAN PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1417159815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN MARIE OVERMAN PTA

Provider Business Mailing Address
First Line	:	722 W MORELAND ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85007-2119
Country	:	US
Telephone Number	:	602-953-9173
Fax Number	:	602-953-9173

Provider Business Practice Location Address
First Line	:	2400 W DUNLAP AVE
Second Line	:	SUITE 145
City	:	PHOENIX
State	:	AZ
Zip	:	85021-2817
Country	:	US
Telephone Number	:	602-870-1414
Fax Number	:	602-870-4141

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	07/08/2007

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