Provider Demographics
NPI:1700416815
Name:BANE, SUSAN CAROL (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAROL
Last Name:BANE
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 VIA DELUNA
Mailing Address - Street 2:D6
Mailing Address - City:PENSACOLA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32561
Mailing Address - Country:US
Mailing Address - Phone:850-292-1407
Mailing Address - Fax:
Practice Address - Street 1:1500 VIA DELUNA
Practice Address - Street 2:D6
Practice Address - City:PENSACOLA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32561
Practice Address - Country:US
Practice Address - Phone:850-292-1407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT5075261QP2000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy