Provider Demographics
NPI:1467628446
Name:HAGGERTY, SUSAN ELLEN (MSPT, AT,C)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ELLEN
Last Name:HAGGERTY
Suffix:
Gender:F
Credentials:MSPT, AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 EMERALD RD SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-3832
Mailing Address - Country:US
Mailing Address - Phone:917-796-3919
Mailing Address - Fax:
Practice Address - Street 1:991 EMERALD RD SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-3832
Practice Address - Country:US
Practice Address - Phone:917-796-3919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012199-1225100000X
FLFL26751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFL26751OtherFLORIDA BOARD OF PHYSICAL THERAPY