Provider Demographics
NPI:1164194239
Name:KIMERIA, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KIMERIA
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 1:230 E NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-5522
Mailing Address - Country:US
Mailing Address - Phone:386-624-6812
Mailing Address - Fax:
Practice Address - Street 1:230 E NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-5522
Practice Address - Country:US
Practice Address - Phone:386-624-6812
Practice Address - Fax:386-624-6812
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112829500Medicaid
FL113844300Medicaid
FL116025500Medicaid