Provider Demographics
NPI:1750606901
Name:SURIN, JEAN MARIO
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:MARIO
Last Name:SURIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 LUCERNE ROAD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01119
Mailing Address - Country:US
Mailing Address - Phone:845-222-9314
Mailing Address - Fax:
Practice Address - Street 1:2112 RIVERDALE STREET
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089
Practice Address - Country:US
Practice Address - Phone:413-827-4375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health