Provider Demographics
NPI:1770933954
Name:MAYO, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MAYO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2436 W PINTURA CT # A
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14615 W FOX CREEK CT
Practice Address - Street 2:
Practice Address - City:BRIMFIELD
Practice Address - State:IL
Practice Address - Zip Code:61517-9529
Practice Address - Country:US
Practice Address - Phone:309-258-0084
Practice Address - Fax:866-319-1546
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist