Provider Demographics
NPI:1477160059
Name:SUKHU, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SUKHU
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 1:3863 WIND DANCER CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34772-8273
Mailing Address - Country:US
Mailing Address - Phone:321-750-6885
Mailing Address - Fax:
Practice Address - Street 1:1820 ARMSTRONG BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2589
Practice Address - Country:US
Practice Address - Phone:407-574-5732
Practice Address - Fax:407-965-4263
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1374672Medicaid