MEDICARE: SUSAN E. WAKELIN P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT1438	FL

General Provider Information

NPI Number	:	1053646505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN E. WAKELIN P.T.

Provider Business Mailing Address
First Line	:	1550 CYPRESS AVE
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-8731
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1550 CYPRESS AVE
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-8731
Country	:	US
Telephone Number	:	386-775-6838
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2009
Last Update Date	:	10/15/2009

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