Provider Demographics
NPI:1508326539
Name:LACONSAY, MARILYN SUERO
Entity Type:Individual
Prefix:MISS
First Name:MARILYN
Middle Name:SUERO
Last Name:LACONSAY
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 1:27299 RIVERVIEW CENTER BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4322
Mailing Address - Country:US
Mailing Address - Phone:239-676-2080
Mailing Address - Fax:239-676-2089
Practice Address - Street 1:27299 RIVERVIEW CENTER BLVD STE 201
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4322
Practice Address - Country:US
Practice Address - Phone:239-676-2080
Practice Address - Fax:239-676-2089
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT6565225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist