Provider Demographics
NPI:1144592403
Name:STAHLY, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:STAHLY
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 1:12617 ROYCE CT
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-2477
Mailing Address - Country:US
Mailing Address - Phone:818-807-8396
Mailing Address - Fax:
Practice Address - Street 1:12617 ROYCE CT
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46033-2477
Practice Address - Country:US
Practice Address - Phone:818-807-8396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-24-72228103K00000X
IN22005317A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst