Provider Demographics
NPI:1629307210
Name:CORSON, SUZANNE
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:CORSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 N COUNTY RD
Mailing Address - Street 2:
Mailing Address - City:HAMPDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04444-3401
Mailing Address - Country:US
Mailing Address - Phone:207-862-3528
Mailing Address - Fax:
Practice Address - Street 1:35 N COUNTY RD
Practice Address - Street 2:
Practice Address - City:HAMPDEN
Practice Address - State:ME
Practice Address - Zip Code:04444-3401
Practice Address - Country:US
Practice Address - Phone:207-862-3528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME223780000Medicaid