Provider Demographics
NPI:1790411692
Name:DESA, WANESSA SOUZA (PT)
Entity Type:Individual
Prefix:
First Name:WANESSA
Middle Name:SOUZA
Last Name:DESA
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 1:1500 OAKLEY SEAVER DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1974
Mailing Address - Country:US
Mailing Address - Phone:352-241-0347
Mailing Address - Fax:
Practice Address - Street 1:1500 OAKLEY SEAVER DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1974
Practice Address - Country:US
Practice Address - Phone:352-241-0347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL38886225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist