Provider Demographics
NPI:1598516957
Name:SUERO, IRISNEIDA A
Entity type:Individual
Prefix:
First Name:IRISNEIDA
Middle Name:A
Last Name:SUERO
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 1:12125 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLLEGE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11356-1156
Mailing Address - Country:US
Mailing Address - Phone:917-600-8102
Mailing Address - Fax:
Practice Address - Street 1:12125 8TH AVE
Practice Address - Street 2:
Practice Address - City:COLLEGE POINT
Practice Address - State:NY
Practice Address - Zip Code:11356-1156
Practice Address - Country:US
Practice Address - Phone:917-600-8102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY812175174400000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No174400000XOther Service ProvidersSpecialist