Provider Demographics
NPI:1609807361
Name:CARMONA, SUSAN PATRICIA
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:PATRICIA
Last Name:CARMONA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:PATRICIA
Other - Last Name:OBURCHAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4710 OLD TROY PIKE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-5740
Mailing Address - Country:US
Mailing Address - Phone:937-855-7821
Mailing Address - Fax:937-855-6972
Practice Address - Street 1:4710 OLD TROY PIKE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-5740
Practice Address - Country:US
Practice Address - Phone:937-855-7821
Practice Address - Fax:937-855-6972
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004531-1225X00000X
OHOT6693225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0510772Medicaid
NY11225448OtherCAQH
NY00355344Medicaid
NY00355344Medicaid