Provider Demographics
NPI:1932221579
Name:FORE, SUSAN LANTZ (ITFS)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LANTZ
Last Name:FORE
Suffix:
Gender:F
Credentials:ITFS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23703 GILLIS RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28351-9227
Mailing Address - Country:US
Mailing Address - Phone:910-277-1273
Mailing Address - Fax:
Practice Address - Street 1:10 PARKER LN
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-7903
Practice Address - Country:US
Practice Address - Phone:910-295-3133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3403400Medicaid