Provider Demographics
NPI:1528310117
Name:BROSNAN-MADDOX, SUSAN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BROSNAN-MADDOX
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W BLOXHAM ST
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32306-1200
Mailing Address - Country:US
Mailing Address - Phone:850-645-8690
Mailing Address - Fax:850-644-8994
Practice Address - Street 1:201 WEST BLOXHAM STREET
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301
Practice Address - Country:US
Practice Address - Phone:850-645-8690
Practice Address - Fax:850-644-8994
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 1834235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist