Provider Demographics
NPI:1568695666
Name:FASOLD, SUSAN CATHERINE (LMT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:CATHERINE
Last Name:FASOLD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2949 W STATE ROAD 434
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4458
Mailing Address - Country:US
Mailing Address - Phone:407-421-2347
Mailing Address - Fax:407-889-5446
Practice Address - Street 1:2949 W STATE ROAD 434
Practice Address - Street 2:SUITE 100
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-4458
Practice Address - Country:US
Practice Address - Phone:407-421-2347
Practice Address - Fax:407-889-5446
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 27799225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist