1104490457 NPI number — MRS. SUZANNE JUDITH-ANTONIA PIERRE

Table of content: MRS. SUZANNE JUDITH-ANTONIA PIERRE (NPI 1104490457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104490457 NPI number — MRS. SUZANNE JUDITH-ANTONIA PIERRE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PIERRE
Provider First Name:
SUZANNE
Provider Middle Name:
JUDITH-ANTONIA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PIERRE
Provider Other First Name:
SUZANNE
Provider Other Middle Name:
JUDITH-ANTONIA
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S., CCC-SLP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1104490457
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6586 HYPOLUXO RD # 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE WORTH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33467-7678
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-710-3040
Provider Business Mailing Address Fax Number:
561-584-5370

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7258 SPINNAKER BAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE WORTH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33467-7669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-710-3040
Provider Business Practice Location Address Fax Number:
561-584-5370
Provider Enumeration Date:
05/19/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SA17007 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 111001700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".