Provider Demographics
NPI:1407124258
Name:BELK, SUSANNE DEROSSITTE (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:SUSANNE
Middle Name:DEROSSITTE
Last Name:BELK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 PETER TRL
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7954
Mailing Address - Country:US
Mailing Address - Phone:870-761-4711
Mailing Address - Fax:
Practice Address - Street 1:3114 FOX RD STE A
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9577
Practice Address - Country:US
Practice Address - Phone:870-203-0296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1-09-5322103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst