Healthcare Provider Details

I. General information

NPI: 1205007754
Provider Name (Legal Business Name): SUSAN WENICK INDEN M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8020 CASTOR AVE
PHILADELPHIA PA
19152-2732
US

IV. Provider business mailing address

8020 CASTOR AVE
PHILADELPHIA PA
19152-2732
US

V. Phone/Fax

Practice location:
  • Phone: 215-722-4111
  • Fax: 215-722-3163
Mailing address:
  • Phone: 215-722-4111
  • Fax: 215-722-3163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231HA2500X
TaxonomyAssistive Technology Supplier Audiologist
License NumberAT000406L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: