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NPI Code Detail

MEDICARE: SUSAN SIDWELL MA

MEDICARE: SUSAN SIDWELL MA
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
1225700000XMassage TherapistMA19765FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MA19765OTHERFLSTATE LIC

General Provider Information

NPI Number : 1740502707
Entity Type Code : Individual
Provider Name (Legal Business Name) : SUSAN SIDWELL MA
Provider Business Mailing Address
First Line : 1000 E HILLSBORO BLVD
Second Line : SUITE 104
City : DEERFIELD BEACH
State : FL
Zip : 33441-3628
Country : US
Telephone Number : 954-363-7494
Fax Number : 954-363-7497
Provider Business Practice Location Address
First Line : 1000 E HILLSBORO BLVD
Second Line : SUITE 104
City : DEERFIELD BEACH
State : FL
Zip : 33441-3628
Country : US
Telephone Number : 954-363-7494
Fax Number : 954-363-7497
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/18/2010
Last Update Date : 02/18/2010

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Directions to “ SUSAN SIDWELL MA” Practice Location

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