Provider Demographics
NPI:1790364859
Name:DE JESUS, SUSANNA (LMT)
Entity Type:Individual
Prefix:MRS
First Name:SUSANNA
Middle Name:
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:SUSANNA
Other - Middle Name:
Other - Last Name:VASQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:91 RYDER AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-2223
Mailing Address - Country:US
Mailing Address - Phone:631-935-3776
Mailing Address - Fax:
Practice Address - Street 1:1147 DEER PARK AVE UNIT A
Practice Address - Street 2:
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703-3103
Practice Address - Country:US
Practice Address - Phone:631-402-4680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225700000X
NY027958-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist