Healthcare Provider Details

I. General information

NPI: 1467376236
Provider Name (Legal Business Name): MRS. SUZANNE DEBAUN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 TIDE CT
WADING RIVER NY
11792-1052
US

IV. Provider business mailing address

42 TIDE CT
WADING RIVER NY
11792-1052
US

V. Phone/Fax

Practice location:
  • Phone: 631-849-3110
  • Fax:
Mailing address:
  • Phone: 631-849-3110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number01790901
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: