Healthcare Provider Details

I. General information

NPI: 1548730146
Provider Name (Legal Business Name): SUSANA DELGADO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSANA JIMENEZ

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 CASCADE RD SE
GRAND RAPIDS MI
49546-8384
US

IV. Provider business mailing address

4106 CROOKED TREE RD SW APT 9
WYOMING MI
49519-5235
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-5570
  • Fax:
Mailing address:
  • Phone: 269-267-6690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: