Provider Demographics
NPI:1124051149
Name:GUSMAN, STANLEY (PT)
Entity type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:
Last Name:GUSMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 APEX DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1282
Mailing Address - Country:US
Mailing Address - Phone:618-651-0444
Mailing Address - Fax:
Practice Address - Street 1:9060 KIMBERLY BLVD
Practice Address - Street 2:#44
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434-2842
Practice Address - Country:US
Practice Address - Phone:561-482-7474
Practice Address - Fax:561-482-3791
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 3326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY2297Medicaid