Healthcare Provider Details

I. General information

NPI: 1831292705
Provider Name (Legal Business Name): SUSAN CLAIRE GEBO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

769 FARMINGTON AVE STE D, BOX 12
FARMINGTON CT
06032-2366
US

IV. Provider business mailing address

769 FARMINGTON AVE STE D, BOX 12
FARMINGTON CT
06032-2366
US

V. Phone/Fax

Practice location:
  • Phone: 860-930-9022
  • Fax:
Mailing address:
  • Phone: 860-930-9022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number000176
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: