Provider Demographics
NPI:1245988948
Name:MALLARD, SUZANNE MARIE (RBT)
Entity type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:MARIE
Last Name:MALLARD
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 FERGUSON DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32805-1021
Mailing Address - Country:US
Mailing Address - Phone:407-807-6887
Mailing Address - Fax:
Practice Address - Street 1:644 FERGUSON DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-1021
Practice Address - Country:US
Practice Address - Phone:407-807-6887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-13
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-183699106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician