Provider Demographics
NPI:1780442111
Name:SUYDAM, LATONIA D (CPRS)
Entity type:Individual
Prefix:
First Name:LATONIA
Middle Name:D
Last Name:SUYDAM
Suffix:
Gender:F
Credentials:CPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:UNION BEACH
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-3147
Mailing Address - Country:US
Mailing Address - Phone:732-770-8596
Mailing Address - Fax:
Practice Address - Street 1:540 BORDENTOWN AVE STE 203
Practice Address - Street 2:
Practice Address - City:SOUTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08879-1546
Practice Address - Country:US
Practice Address - Phone:732-963-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJCPRS-50275175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist