Provider Demographics
NPI:1679594709
Name:DE WERD, SUSAN LYNN (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:DE WERD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 SAPPHIRE LN
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-8806
Mailing Address - Country:US
Mailing Address - Phone:760-598-8955
Mailing Address - Fax:
Practice Address - Street 1:1540 SAPPHIRE LN
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-8806
Practice Address - Country:US
Practice Address - Phone:760-598-8955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 15541225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist