=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235365115
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALISA DANGSUPA P.T., D.P.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2009
-----------------------------------------------------
Last Update Date | 06/05/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3820 COLONIAL BLVD SUITE 103
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33966-1094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-275-4411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15340 WILL LEW LN
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33908-4247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-431-2052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 24639
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------