Provider Demographics
NPI:1528149077
Name:BACKSTROM, SUZANNE MARIE (PT)
Entity type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:MARIE
Last Name:BACKSTROM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1154 PARADISE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159
Mailing Address - Country:US
Mailing Address - Phone:865-604-5182
Mailing Address - Fax:
Practice Address - Street 1:1550 KILLINGSWORTH WAY
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-2175
Practice Address - Country:US
Practice Address - Phone:352-205-7761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT29376225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist