MEDICARE: MRS. SUSAN G CHILDERS 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	SLP004781	GA

General Provider Information

NPI Number	:	1780854273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN G CHILDERS CCC-SLP

Provider Business Mailing Address
First Line	:	175 KRISTIN CT
Second Line	:
City	:	COLBERT
State	:	GA
Zip	:	30628-2933
Country	:	US
Telephone Number	:	706-788-3323
Fax Number	:	706-788-0062

Provider Business Practice Location Address
First Line	:	613 COOK ST
Second Line	:
City	:	ROYSTON
State	:	GA
Zip	:	30662-3933
Country	:	US
Telephone Number	:	706-245-1822
Fax Number	:

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

Provider Enumeration Date	:	03/11/2008
Last Update Date	:	03/11/2008

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