Provider Demographics
NPI:1730479338
Name:MONGEON, SUSAN (OT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MONGEON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 BUCK ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-6923
Mailing Address - Country:US
Mailing Address - Phone:336-782-4108
Mailing Address - Fax:
Practice Address - Street 1:70 BUCK ISLAND RD
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-6923
Practice Address - Country:US
Practice Address - Phone:336-782-4108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3804225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist