Provider Demographics
NPI:1700987724
Name:IDE, SUSAN (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:IDE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 NW 10TH AVE
Mailing Address - Street 2:#201
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-1312
Mailing Address - Country:US
Mailing Address - Phone:561-338-6100
Mailing Address - Fax:561-338-6434
Practice Address - Street 1:1500 NW 10TH AVE
Practice Address - Street 2:#201
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-1312
Practice Address - Country:US
Practice Address - Phone:561-338-6100
Practice Address - Fax:561-338-6434
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT002678225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ8148AMedicare ID - Type UnspecifiedOCCUPATIONAL THERAPIST