Provider Demographics
NPI:1376032979
Name:SOGAR, SUSANNE
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:SOGAR
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 1:251 ALBATROSS ST
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33931-4503
Mailing Address - Country:US
Mailing Address - Phone:214-843-4826
Mailing Address - Fax:
Practice Address - Street 1:2734 OAK RIDGE CT STE 404
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9369
Practice Address - Country:US
Practice Address - Phone:239-963-4367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH15902101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health