Provider Demographics
NPI:1699086066
Name:MATHES, SUZETTE ALENE (COTA)
Entity type:Individual
Prefix:
First Name:SUZETTE
Middle Name:ALENE
Last Name:MATHES
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:SUZETTE
Other - Middle Name:ALENE
Other - Last Name:BEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12083 LENOVER ST
Mailing Address - Street 2:
Mailing Address - City:DILLSBORO
Mailing Address - State:IN
Mailing Address - Zip Code:47018
Mailing Address - Country:US
Mailing Address - Phone:812-432-5226
Mailing Address - Fax:812-432-5286
Practice Address - Street 1:12083 LENOVER ST
Practice Address - Street 2:
Practice Address - City:DILLSBORO
Practice Address - State:IN
Practice Address - Zip Code:47018
Practice Address - Country:US
Practice Address - Phone:812-432-5226
Practice Address - Fax:812-432-5286
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32000108A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant