=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659688869
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN MARDJETKO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2010
-----------------------------------------------------
Last Update Date | 10/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7927 STATE ROAD 52 ATRIA BAYPOINT VILLAGE
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-378-8586
-----------------------------------------------------
Fax | 727-378-8587
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7927 STATE ROAD 52
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-378-8586
-----------------------------------------------------
Fax | 727-378-8587
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SA2502
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------