Provider Demographics
NPI:1306368386
Name:CROSS, SUSAN R (MS, LATC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:CROSS
Suffix:
Gender:F
Credentials:MS, LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33701 ST RD 52
Mailing Address - Street 2:MSC 2038
Mailing Address - City:SAINT LEO
Mailing Address - State:FL
Mailing Address - Zip Code:33603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33701 ST RD 52
Practice Address - Street 2:
Practice Address - City:SAINT LEO
Practice Address - State:FL
Practice Address - Zip Code:33574
Practice Address - Country:US
Practice Address - Phone:352-588-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL39052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer