Provider Demographics
NPI:1043521271
Name:HALL, SUSAN E (SLP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:HALL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 SUSIE DR
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-9527
Mailing Address - Country:US
Mailing Address - Phone:208-582-3605
Mailing Address - Fax:208-245-2138
Practice Address - Street 1:820 ELM DR
Practice Address - Street 2:
Practice Address - City:ST MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-2119
Practice Address - Country:US
Practice Address - Phone:208-245-4576
Practice Address - Fax:208-245-2138
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1946235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0026109Medicaid