Provider Demographics
NPI:1144305848
Name:PERILLO, SUSAN JEAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:JEAN
Last Name:PERILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 PRE EMPTION RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1334
Mailing Address - Country:US
Mailing Address - Phone:315-789-7611
Mailing Address - Fax:315-789-8136
Practice Address - Street 1:650 PRE EMPTION RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1334
Practice Address - Country:US
Practice Address - Phone:315-789-7611
Practice Address - Fax:315-789-8136
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008633-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist