Provider Demographics
NPI:1285866962
Name:TWEETEN, SUSAN (PSYD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:TWEETEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 S LAKE JESSUP AVE
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-8726
Mailing Address - Country:US
Mailing Address - Phone:407-808-4190
Mailing Address - Fax:
Practice Address - Street 1:905 S LAKE JESSUP AVE
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-8726
Practice Address - Country:US
Practice Address - Phone:407-808-4190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-14
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9261103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY610661458OtherGROUP TAX ID NUMBER