Provider Demographics
NPI:1114265162
Name:SUE, FELICIA ANN (PT)
Entity Type:Individual
Prefix:
First Name:FELICIA
Middle Name:ANN
Last Name:SUE
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 1:4444 PECOS AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94555-3232
Mailing Address - Country:US
Mailing Address - Phone:510-745-8386
Mailing Address - Fax:
Practice Address - Street 1:100 S SAN MATEO DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3805
Practice Address - Country:US
Practice Address - Phone:650-696-4065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-26
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29962225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist