Basic Information
Provider Information | |||||||||
NPI: | 1154683159 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LOUIS | ||||||||
FirstName: | SUWENDA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 541 SW 63RD AVE | ||||||||
Address2: |   | ||||||||
City: | MARGATE | ||||||||
State: | FL | ||||||||
PostalCode: | 330681730 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7542149842 | ||||||||
FaxNumber: | 9545777780 | ||||||||
Practice Location | |||||||||
Address1: | 1239 E NEWPORT CENTER DR STE 101 | ||||||||
Address2: |   | ||||||||
City: | DEERFIELD BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334427711 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7544443707 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2012 | ||||||||
LastUpdateDate: | 06/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 103K00000X | 1-18-30663 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
No ID Information.