Provider Demographics
NPI:1629267927
Name:DIVETT, SUZANNE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:
Last Name:DIVETT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 MONTREAL LOOP NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-8455
Mailing Address - Country:US
Mailing Address - Phone:505-867-0711
Mailing Address - Fax:
Practice Address - Street 1:4101 MONTREAL LOOP NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-8455
Practice Address - Country:US
Practice Address - Phone:505-867-0711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM30752060Medicaid