Provider Demographics
NPI:1831292705
Name:GEBO, SUSAN CLAIRE (RD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CLAIRE
Last Name:GEBO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 FARMINGTON AVE
Mailing Address - Street 2:SUITE 25
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1587
Mailing Address - Country:US
Mailing Address - Phone:860-232-5415
Mailing Address - Fax:860-231-1696
Practice Address - Street 1:99 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1207
Practice Address - Country:US
Practice Address - Phone:860-714-6520
Practice Address - Fax:860-714-8079
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000176133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered