Provider Demographics
NPI:1568674869
Name:WALL, SUZANNE MARIE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:MARIE
Last Name:WALL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:MARIE
Other - Last Name:CARREIRO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:14043 PAM DR
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34614
Mailing Address - Country:US
Mailing Address - Phone:352-596-6779
Mailing Address - Fax:
Practice Address - Street 1:8403 BALM ST
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34607
Practice Address - Country:US
Practice Address - Phone:352-596-7885
Practice Address - Fax:352-596-7886
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA33725225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist