MEDICARE: SUSAN S DUCKLOW PT

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	225100000X	Physical Therapist	7792	CO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	066615	OTHER	CO	MEDICARE GROUP #

General Provider Information

NPI Number	:	1770572604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN S DUCKLOW PT

Provider Business Mailing Address
First Line	:	15 APEX DR
Second Line	:
City	:	HIGHLAND
State	:	IL
Zip	:	62249-1282
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13370 E MARY ANN CLEVELAND WAY STE 130
Second Line	:
City	:	VAIL
State	:	AZ
Zip	:	85641-8611
Country	:	US
Telephone Number	:	520-689-7144
Fax Number	:

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

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	03/04/2020

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