Healthcare Provider Details

I. General information

NPI: 1164722377
Provider Name (Legal Business Name): SUSAN SHOPIRO P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2010
Last Update Date: 10/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 BOSTON AVE
ALTAMONTE SPRINGS FL
32701-4700
US

IV. Provider business mailing address

2913 SUN COVE DR
KISSIMMEE FL
34746-2776
US

V. Phone/Fax

Practice location:
  • Phone: 407-260-0817
  • Fax:
Mailing address:
  • Phone: 407-201-4002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 21651
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number40QB00243800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: