Provider Demographics
NPI:1932637196
Name:ROMAN, SUSAN MARISSA (COTA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARISSA
Last Name:ROMAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 S CANE ST APT 11
Mailing Address - Street 2:
Mailing Address - City:ELLSINORE
Mailing Address - State:MO
Mailing Address - Zip Code:63937-8237
Mailing Address - Country:US
Mailing Address - Phone:928-897-2726
Mailing Address - Fax:
Practice Address - Street 1:3488 JEFFCO BLVD STE 102
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-6015
Practice Address - Country:US
Practice Address - Phone:636-464-5439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025019615224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant