Provider Demographics
NPI:1750588778
Name:SUZUKI, SANDRA BROSE (LCPC)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:BROSE
Last Name:SUZUKI
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MS
Other - First Name:SANDRA
Other - Middle Name:CAROL
Other - Last Name:BROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC, MHC
Mailing Address - Street 1:16184 EDGEMONT DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-3652
Mailing Address - Country:US
Mailing Address - Phone:847-284-0636
Mailing Address - Fax:
Practice Address - Street 1:22904 LYDEN DR
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-7047
Practice Address - Country:US
Practice Address - Phone:239-494-3951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005930101YM0800X
FL24188101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health