Provider Demographics
NPI:1740581602
Name:KLUEVER, ILSE (PT)
Entity Type:Individual
Prefix:MISS
First Name:ILSE
Middle Name:
Last Name:KLUEVER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 MASON AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5103
Mailing Address - Country:US
Mailing Address - Phone:386-274-3460
Mailing Address - Fax:386-274-5513
Practice Address - Street 1:1920 MASON AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5103
Practice Address - Country:US
Practice Address - Phone:386-274-3460
Practice Address - Fax:386-274-5513
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25471225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist