Provider Demographics
NPI:1598466989
Name:LADDUSAW, EMILY (PTA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:LADDUSAW
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3398 TALISMAN DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-7851
Mailing Address - Country:US
Mailing Address - Phone:361-455-7621
Mailing Address - Fax:
Practice Address - Street 1:1835 EASTWEST PKWY
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-6336
Practice Address - Country:US
Practice Address - Phone:904-215-3958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTAT32630225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant