Provider Demographics
NPI:1821120999
Name:RANDALL, SUZANNE M (LMT)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:M
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 17TH AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-3103
Mailing Address - Country:US
Mailing Address - Phone:941-755-7060
Mailing Address - Fax:
Practice Address - Street 1:5190 26TH ST W
Practice Address - Street 2:SUITE - E
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-2255
Practice Address - Country:US
Practice Address - Phone:941-755-7060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMM10068225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist