Basic Information
Provider Information | |||||||||
NPI: | 1003337684 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLITMAN | ||||||||
FirstName: | SUSI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMHC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10286 HARBOR INN CT | ||||||||
Address2: |   | ||||||||
City: | CORAL SPRINGS | ||||||||
State: | FL | ||||||||
PostalCode: | 330715622 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9545473414 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2010 NW 150TH AVE | ||||||||
Address2: |   | ||||||||
City: | PEMBROKE PINES | ||||||||
State: | FL | ||||||||
PostalCode: | 330282887 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9544319838 | ||||||||
FaxNumber: | 9547792316 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/04/2017 | ||||||||
LastUpdateDate: | 10/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH15054 | FL | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | MH15054 | 01 | FL | MENTAL HEALTH COUNSELING LICENSE | OTHER |