Provider Demographics
NPI:1154683159
Name:LOUIS, SUWENDA
Entity Type:Individual
Prefix:
First Name:SUWENDA
Middle Name:
Last Name:LOUIS
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 1:541 SW 63RD AVE
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-1730
Mailing Address - Country:US
Mailing Address - Phone:754-214-9842
Mailing Address - Fax:954-577-7780
Practice Address - Street 1:1239 E NEWPORT CENTER DR STE 101
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-7711
Practice Address - Country:US
Practice Address - Phone:754-444-3707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL1-18-30663103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty