Provider Demographics
NPI:1285950832
Name:SUPER, JOHN THOMAS (MA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:THOMAS
Last Name:SUPER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 141502
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-1502
Mailing Address - Country:US
Mailing Address - Phone:407-770-1201
Mailing Address - Fax:407-898-0858
Practice Address - Street 1:938 LAKE BALDWIN LN
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6651
Practice Address - Country:US
Practice Address - Phone:407-770-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT1331106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist