Healthcare Provider Details

I. General information

NPI: 1992845994
Provider Name (Legal Business Name): SUSAN ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 HAWICK DR
VALPARAISO IN
46385-9331
US

IV. Provider business mailing address

81 HAWICK DR
VALPARAISO IN
46385-9331
US

V. Phone/Fax

Practice location:
  • Phone: 219-928-5413
  • Fax: 775-251-7620
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22001194A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: