Provider Demographics
NPI:1881230845
Name:SCOTT SUESBERRY, LATICIA (CERTIFIED HAIR LOSS)
Entity Type:Individual
Prefix:
First Name:LATICIA
Middle Name:
Last Name:SCOTT SUESBERRY
Suffix:
Gender:F
Credentials:CERTIFIED HAIR LOSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-5401
Mailing Address - Country:US
Mailing Address - Phone:254-554-7428
Mailing Address - Fax:
Practice Address - Street 1:4200 W STAN SCHLUETER LOOP STE B200
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-6937
Practice Address - Country:US
Practice Address - Phone:254-554-7428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management