Provider Demographics
NPI:1720061971
Name:GLOVER, SUSAN MARIE (PT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:GLOVER
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 1:1214 TENNESSEE AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-2265
Mailing Address - Country:US
Mailing Address - Phone:765-617-0042
Mailing Address - Fax:
Practice Address - Street 1:1500 WHITE POINT RD
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-4249
Practice Address - Country:US
Practice Address - Phone:850-896-5592
Practice Address - Fax:850-897-0501
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL32703225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist