Provider Demographics
NPI:1194915215
Name:SISULAK, CYNTHIA A (PT)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:A
Last Name:SISULAK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:CYNTHIA
Other - Middle Name:A
Other - Last Name:RITTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:17532 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MONTVERDE
Mailing Address - State:FL
Mailing Address - Zip Code:34756-3184
Mailing Address - Country:US
Mailing Address - Phone:262-720-5855
Mailing Address - Fax:
Practice Address - Street 1:14055 TOWN LOOP BLVD
Practice Address - Street 2:300
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-6106
Practice Address - Country:US
Practice Address - Phone:262-720-5855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30463225100000X
FLPT 304632251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016455100Medicaid