Provider Demographics
NPI:1740502707
Name:SIDWELL, SUSAN (MA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SIDWELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:GARRASTEGUI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:1000 E HILLSBORO BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-3628
Mailing Address - Country:US
Mailing Address - Phone:954-363-7494
Mailing Address - Fax:954-363-7497
Practice Address - Street 1:1000 E HILLSBORO BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-3628
Practice Address - Country:US
Practice Address - Phone:954-363-7494
Practice Address - Fax:954-363-7497
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA19765225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA19765OtherSTATE LIC