Provider Demographics
NPI:1841308707
Name:GAMMON, SUSAN (PT)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:GAMMON
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 1:5085 N BEACH RD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34223-9032
Mailing Address - Country:US
Mailing Address - Phone:561-512-7068
Mailing Address - Fax:941-451-2073
Practice Address - Street 1:500 ROCKLEY BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-4300
Practice Address - Country:US
Practice Address - Phone:561-512-7068
Practice Address - Fax:941-451-2073
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19997225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY1288AMedicare PIN