Basic Information
| Provider Information | |||||||||
| NPI: | 1144341264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | SUZANNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 S FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547281012 | ||||||||
| FaxNumber: | 9547792316 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 S FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547281012 | ||||||||
| FaxNumber: | 9547792316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 01/17/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251P0200X | PT6812 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 222Q00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 883762700 | 05 | FL | MEDICAID | 811436600 | 05 | FL | MEDICAID |