=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932137494
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN MARIE KANE PT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2006
-----------------------------------------------------
Last Update Date | 10/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3000 WOODMONT AVE
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33884-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-293-1191
-----------------------------------------------------
Fax | 863-508-2277
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 E CENTRAL AVE
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33880-3094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-293-1191
-----------------------------------------------------
Fax | 863-507-2227
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AL 1108
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT 19127
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------