MEDICARE: MRS. SUSAN E. BLACK SR. MS,CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	2002202317	VA

General Provider Information

NPI Number	:	1366599565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN E. BLACK SR. MS,CCC-SLP

Provider Business Mailing Address
First Line	:	3420 LAKEVIEW PKWY
Second Line	:
City	:	LOCUST GROVE
State	:	VA
Zip	:	22508-5664
Country	:	US
Telephone Number	:	540-972-9606
Fax Number	:

Provider Business Practice Location Address
First Line	:	3420 LAKEVIEW PKWY
Second Line	:
City	:	LOCUST GROVE
State	:	VA
Zip	:	22508-5664
Country	:	US
Telephone Number	:	540-972-9606
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/08/2007

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Directions to “ MRS. SUSAN E. BLACK SR. MS,CCC-SLP” Practice Location

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