Basic Information
| Provider Information | |||||||||
| NPI: | 1629571385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WASSOUF | ||||||||
| OtherFirstName: | SUZANNE | ||||||||
| OtherMiddleName: | CHRISTINE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1377 MOTOR PKWY STE 307 | ||||||||
| Address2: | |||||||||
| City: | ISLANDIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117495258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315805200 | ||||||||
| FaxNumber: | 6315805222 | ||||||||
| Practice Location | |||||||||
| Address1: | 945 E SHERMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317374374 | ||||||||
| FaxNumber: | 2318309196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2018 | ||||||||
| LastUpdateDate: | 10/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501017160 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5501017160 | 05 | MI | MEDICAID |