Basic Information
| Provider Information | |||||||||
| NPI: | 1245319862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3760 CONVOY ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921113743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582641434 | ||||||||
| FaxNumber: | 8587510901 | ||||||||
| Practice Location | |||||||||
| Address1: | 552 S PASEO DOROTEA STE 4 | ||||||||
| Address2: | |||||||||
| City: | PALM SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922641437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603255950 | ||||||||
| FaxNumber: | 7603255945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT22727 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1191167 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 292199 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT22727 | 01 | FL | STATE LICENSE | OTHER | TXB116253 | 01 | TX | PTAN | OTHER |