Basic Information
| Provider Information | |||||||||
| NPI: | 1285782839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BATES | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BATES | ||||||||
| OtherFirstName: | ANITA | ||||||||
| OtherMiddleName: | SUSAN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12751 HIGHWAY 491 S | ||||||||
| Address2: | |||||||||
| City: | UNION | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393658546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016566827 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 711 AVIGNON DR | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391575120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016056777 | ||||||||
| FaxNumber: | 6016058869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT0886 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.