Provider Demographics
NPI:1932137494
Name:KANE, SUSAN MARIE (PT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:KANE
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S FLORIDA AVE STE 620
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-5269
Mailing Address - Country:US
Mailing Address - Phone:636-881-8008
Mailing Address - Fax:863-688-1824
Practice Address - Street 1:500 S FLORIDA AVE STE 620
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5269
Practice Address - Country:US
Practice Address - Phone:863-688-1800
Practice Address - Fax:863-688-1824
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 11082255A2300X
FLPT 19127225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY134FOtherBLUE CROSS BLUE SHIELD
FL113582100Medicaid
FLAT306ZMedicare PIN