Healthcare Provider Details

I. General information

NPI: 1720739394
Provider Name (Legal Business Name): SUSAN O'CONNOR BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 COASTAL OAK CIR
PONTE VEDRA BEACH FL
32082-2702
US

IV. Provider business mailing address

168 COASTAL OAK CIR
PONTE VEDRA BEACH FL
32082-2702
US

V. Phone/Fax

Practice location:
  • Phone: 610-639-4554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY11787
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS008999L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: