MEDICARE: SUSAN WHITLEY

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	146013190	IL

General Provider Information

NPI Number	:	1215483060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN WHITLEY

Provider Business Mailing Address
First Line	:	11960 WESTLINE INDUSTRIAL DR
Second Line	:	SUITE 201
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-3209
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5319 LANSDOWNE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-2311
Country	:	US
Telephone Number	:	314-352-4343
Fax Number	:

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

Provider Enumeration Date	:	08/31/2016
Last Update Date	:	08/31/2016

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Directions to “ SUSAN WHITLEY ” Practice Location

Language	Start Address	Practice Location

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