Healthcare Provider Details

I. General information

NPI: 1174126478
Provider Name (Legal Business Name): DANIELLE KAY CUDDEBACK PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 SW BELLEVUE AVE
PORT SAINT LUCIE FL
34953-1035
US

IV. Provider business mailing address

1850 SW BELLEVUE AVE
PORT ST LUCIE FL
34953-1035
US

V. Phone/Fax

Practice location:
  • Phone: 607-345-4221
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number34874
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: