Provider Demographics
NPI:1336885672
Name:SUSDORF, TAYLOR (PT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:SUSDORF
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:
Other - Last Name:SEPULEVDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:41604 BIG SAGE CT
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-1547
Mailing Address - Country:US
Mailing Address - Phone:951-252-7928
Mailing Address - Fax:
Practice Address - Street 1:24271 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-1993
Practice Address - Country:US
Practice Address - Phone:925-640-6240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA296318225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty