Provider Demographics
NPI:1548336829
Name:LASCANO, SUSAN MANDY (MPT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MANDY
Last Name:LASCANO
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 MEDICAL BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-1417
Mailing Address - Country:US
Mailing Address - Phone:239-593-3501
Mailing Address - Fax:239-593-3505
Practice Address - Street 1:1706 MEDICAL BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-1417
Practice Address - Country:US
Practice Address - Phone:239-593-3501
Practice Address - Fax:239-593-3505
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20073225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE7032YMedicare ID - Type Unspecified