Healthcare Provider Details

I. General information

NPI: 1184702300
Provider Name (Legal Business Name): SUZANNE CHAMPAGNE EUSEBIO LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 CENTER ST STE 100
CAPE CANAVERAL FL
32920-3740
US

IV. Provider business mailing address

166 CENTER ST STE 100
CAPE CANAVERAL FL
32920-3740
US

V. Phone/Fax

Practice location:
  • Phone: 860-460-5542
  • Fax:
Mailing address:
  • Phone: 860-460-5542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number000979
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: