Provider Demographics
NPI:1629571385
Name:LOPEZ, SUZANNE CHRISTINE (DPT)
Entity type:Individual
Prefix:MISS
First Name:SUZANNE
Middle Name:CHRISTINE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:CHRISTINE
Other - Last Name:WASSOUF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1377 MOTOR PKWY STE 307
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:945 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1805
Practice Address - Country:US
Practice Address - Phone:231-737-4374
Practice Address - Fax:231-830-9196
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017160225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501017160Medicaid