Provider Demographics
NPI:1689445827
Name:STATEN, SUSAN RENEE
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RENEE
Last Name:STATEN
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 1:3888 WOODMERE PARK BLVD APT 14
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-5268
Mailing Address - Country:US
Mailing Address - Phone:941-504-5958
Mailing Address - Fax:
Practice Address - Street 1:2886 RINGLING BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34237-5331
Practice Address - Country:US
Practice Address - Phone:941-954-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA46431225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist