Provider Demographics
NPI:1215604905
Name:FRY, SUSAN RENEE
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RENEE
Last Name:FRY
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 1:935 STATE ROUTE VV
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-3822
Mailing Address - Country:US
Mailing Address - Phone:573-888-5925
Mailing Address - Fax:
Practice Address - Street 1:935 STATE ROUTE VV
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3822
Practice Address - Country:US
Practice Address - Phone:573-888-5925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician