Provider Demographics
NPI:1104252915
Name:SUSLOV, NATALIA (OTR)
Entity type:Individual
Prefix:MS
First Name:NATALIA
Middle Name:
Last Name:SUSLOV
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 WILLIAMSBURG DR
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2547
Mailing Address - Country:US
Mailing Address - Phone:347-578-6063
Mailing Address - Fax:
Practice Address - Street 1:11 WILLIAMSBURG DR
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2547
Practice Address - Country:US
Practice Address - Phone:347-578-6063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY312091225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY312091OtherNBCOT