Provider Demographics
NPI:1659564565
Name:ANTON, SUSAN S (LMT)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:S
Last Name:ANTON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:G
Other - Last Name:ANTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:15800 NE 148TH TERRACE RD
Mailing Address - Street 2:
Mailing Address - City:FORT MC COY
Mailing Address - State:FL
Mailing Address - Zip Code:32134-8071
Mailing Address - Country:US
Mailing Address - Phone:352-812-0109
Mailing Address - Fax:
Practice Address - Street 1:15800 NE 148TH TERRACE RD
Practice Address - Street 2:
Practice Address - City:FORT MC COY
Practice Address - State:FL
Practice Address - Zip Code:32134-8071
Practice Address - Country:US
Practice Address - Phone:352-812-0109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA47748172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC2621OtherBLUE CROSS/ BLUE SHIELD