Provider Demographics
NPI:1093951527
Name:DAVEIRO, SUSAN WASSERMANN
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:WASSERMANN
Last Name:DAVEIRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 GASTON DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-9460
Mailing Address - Country:US
Mailing Address - Phone:252-330-1318
Mailing Address - Fax:
Practice Address - Street 1:104 GASTON DR
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-9460
Practice Address - Country:US
Practice Address - Phone:252-330-1318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-06
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC252Y00000X, 101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool