Provider Demographics
NPI:1336703016
Name:KLOOSTERMAN, CONSUELO CECILIA
Entity Type:Individual
Prefix:
First Name:CONSUELO
Middle Name:CECILIA
Last Name:KLOOSTERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12598 TORBAY DR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-4835
Mailing Address - Country:US
Mailing Address - Phone:561-451-1464
Mailing Address - Fax:
Practice Address - Street 1:12598 TORBAY DR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-4835
Practice Address - Country:US
Practice Address - Phone:561-451-1464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-28
Last Update Date:2019-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8404225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist