Healthcare Provider Details

I. General information

NPI: 1437344116
Provider Name (Legal Business Name): DR. SUZANNE BENNETT JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 WEST CALL STREET COLLEGE OF MEDICINE FLORIDA STATE UNIVERSITY
TALLAHASSEE FL
32306-4300
US

IV. Provider business mailing address

1115 WEST CALL STREET DEPARTMENT OF MEDICAL HUMANITIES AND SOCIAL SERVICES FS
TALLAHASSEE FL
32306-4300
US

V. Phone/Fax

Practice location:
  • Phone: 850-644-3457
  • Fax: 850-645-1773
Mailing address:
  • Phone: 850-644-3457
  • Fax: 850-645-1773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY2320
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: