Healthcare Provider Details

I. General information

NPI: 1336404300
Provider Name (Legal Business Name): MRS. MARY SUZETTA HORN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2012
Last Update Date: 07/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

544 GENERAL CRUFT
RICHMOND KY
40475-8887
US

IV. Provider business mailing address

544 GENERAL CRUFT DR
RICHMOND KY
40475-8887
US

V. Phone/Fax

Practice location:
  • Phone: 859-661-2423
  • Fax:
Mailing address:
  • Phone: 859-661-2423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number000042294
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: