Provider Demographics
NPI:1275264970
Name:TAMEZ, SUSANA
Entity Type:Individual
Prefix:MISS
First Name:SUSANA
Middle Name:
Last Name:TAMEZ
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 1:516 SAN LUIZ AVE
Mailing Address - Street 2:
Mailing Address - City:CLEWISTON
Mailing Address - State:FL
Mailing Address - Zip Code:33440-0257
Mailing Address - Country:US
Mailing Address - Phone:863-233-8491
Mailing Address - Fax:
Practice Address - Street 1:516 SAN LUIZ AVE
Practice Address - Street 2:
Practice Address - City:CLEWISTON
Practice Address - State:FL
Practice Address - Zip Code:33440-0257
Practice Address - Country:US
Practice Address - Phone:863-233-8491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH22402101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health