MEDICARE: SUSAN C STEVENSON MS, ATC/L

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	174400000X	Specialist		IL

General Provider Information

NPI Number	:	1962470013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN C STEVENSON MS, ATC/L

Provider Business Mailing Address
First Line	:	5050 E STATE ST
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2311
Country	:	US
Telephone Number	:	815-394-5075
Fax Number	:

Provider Business Practice Location Address
First Line	:	5050 E STATE ST
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2311
Country	:	US
Telephone Number	:	815-394-5075
Fax Number	:	815-394-5077

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

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	07/08/2007

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