Provider Demographics
NPI:1285653527
Name:WALTERS, SUZANNE SUTTERFIELD (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:SUTTERFIELD
Last Name:WALTERS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LAKE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8291
Mailing Address - Country:US
Mailing Address - Phone:601-346-9191
Mailing Address - Fax:601-346-5011
Practice Address - Street 1:7213 SIWELL ROAD
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272
Practice Address - Country:US
Practice Address - Phone:601-346-9191
Practice Address - Fax:601-346-5011
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1421225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02377597Medicaid
MS02377597Medicaid