Provider Demographics
NPI:1104979863
Name:PAGE, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PAGE
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 1:259 E OAKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-3547
Mailing Address - Country:US
Mailing Address - Phone:850-628-1234
Mailing Address - Fax:850-689-8799
Practice Address - Street 1:7 VINE AVE NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5070
Practice Address - Country:US
Practice Address - Phone:850-863-2873
Practice Address - Fax:850-862-9292
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH3244101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health