Provider Demographics
NPI:1508923665
Name:CHARNAM, SUSAN B (ITDS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:CHARNAM
Suffix:
Gender:F
Credentials:ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10719 NW 49TH MNR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-2707
Mailing Address - Country:US
Mailing Address - Phone:954-234-0951
Mailing Address - Fax:954-755-2782
Practice Address - Street 1:10719 NW 49TH MNR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33076-2707
Practice Address - Country:US
Practice Address - Phone:954-234-0951
Practice Address - Fax:954-755-2782
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8117918Medicaid