Provider Demographics
NPI:1164722377
Name:SHOPIRO, SUSAN (PTA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SHOPIRO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2913 SUN COVE DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-2776
Mailing Address - Country:US
Mailing Address - Phone:407-201-4002
Mailing Address - Fax:
Practice Address - Street 1:217 BOSTON AVE
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-4700
Practice Address - Country:US
Practice Address - Phone:407-260-0817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 21651225200000X
NJ40QB00243800225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant