Provider Demographics
NPI:1477194660
Name:MRAZ, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MRAZ
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 1:256 FIR GROVE RD
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4816
Mailing Address - Country:US
Mailing Address - Phone:631-245-9316
Mailing Address - Fax:
Practice Address - Street 1:256 FIR GROVE RD
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-4816
Practice Address - Country:US
Practice Address - Phone:631-245-9316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency