1720127491 NPI number — MRS. SUZANNE STEPHANIE GLAZE OTD, OTRL, CHT

Table of content: MRS. SUZANNE STEPHANIE GLAZE OTD, OTRL, CHT (NPI 1720127491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720127491 NPI number — MRS. SUZANNE STEPHANIE GLAZE OTD, OTRL, CHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLAZE
Provider First Name:
SUZANNE
Provider Middle Name:
STEPHANIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTD, OTRL, CHT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720127491
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3901 UNIVERSITY BLVD S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32216-4312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9 PINE CONE DR
Provider Second Line Business Practice Location Address:
SUITE 104-B
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32137-8686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-446-9716
Provider Business Practice Location Address Fax Number:
386-446-0046
Provider Enumeration Date:
02/06/2007

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: 225X00000X , with the licence number:  OT-3084 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XH1200X , with the licence number: OT-3084 , 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)





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