Provider Demographics
NPI:1154850089
Name:DOYLE-ROEDER, SUZAN K (MS, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:SUZAN
Middle Name:K
Last Name:DOYLE-ROEDER
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:SUZAN
Other - Middle Name:K
Other - Last Name:HAMILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2021 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-2607
Mailing Address - Country:US
Mailing Address - Phone:417-413-1555
Mailing Address - Fax:417-761-5011
Practice Address - Street 1:2021 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-2607
Practice Address - Country:US
Practice Address - Phone:417-413-1555
Practice Address - Fax:833-473-0885
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016039485103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO730043218Medicaid