Provider Demographics
NPI:1508409129
Name:BURBANK, SUZANNE MICHELE (OTR/L, CLT)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MICHELE
Last Name:BURBANK
Suffix:
Gender:F
Credentials:OTR/L, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N WICKHAM RD STE 103
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8628
Mailing Address - Country:US
Mailing Address - Phone:239-822-8846
Mailing Address - Fax:
Practice Address - Street 1:405 N WICKHAM RD STE 103
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8628
Practice Address - Country:US
Practice Address - Phone:321-327-8509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-27
Last Update Date:2019-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4427225X00000X
FL14748225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist