Provider Demographics
NPI:1235365115
Name:DANGSUPA, ALISA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:DANGSUPA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15340 WILL LEW LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4247
Mailing Address - Country:US
Mailing Address - Phone:813-431-2052
Mailing Address - Fax:
Practice Address - Street 1:3820 COLONIAL BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1094
Practice Address - Country:US
Practice Address - Phone:239-275-4411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24639225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist