Provider Demographics
NPI:1043608193
Name:BLANCO, SUZETTE NICOLE (DPT)
Entity type:Individual
Prefix:DR
First Name:SUZETTE
Middle Name:NICOLE
Last Name:BLANCO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 NW 195TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-3271
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2685 EXECUTIVE PARK DR STE 4
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3651
Practice Address - Country:US
Practice Address - Phone:954-515-0892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-23
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLPT29979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014078000Medicaid