Basic Information
| Provider Information | |||||||||
| NPI: | 1427543099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CACERES | ||||||||
| FirstName: | SUSANA | ||||||||
| MiddleName: | SARA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2530 MERIDIAN PKWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277135273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195649717 | ||||||||
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| Practice Location | |||||||||
| Address1: | 716 MARSH RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282091851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045229912 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2018 | ||||||||
| LastUpdateDate: | 08/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-21-52621 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.