Provider Demographics
NPI:1538617600
Name:STALEY, SUSAN MARIE (SLP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:STALEY
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 1:5795 N F ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-2660
Mailing Address - Country:US
Mailing Address - Phone:909-240-6240
Mailing Address - Fax:
Practice Address - Street 1:5795 N F ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-2660
Practice Address - Country:US
Practice Address - Phone:909-240-6240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14489235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist