Provider Demographics
NPI:1548468184
Name:BURNS, SUSAN L (HIS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:BURNS
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6225 RITA ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8805
Mailing Address - Country:US
Mailing Address - Phone:508-274-1746
Mailing Address - Fax:
Practice Address - Street 1:4331 E. MAIN ST.
Practice Address - Street 2:SUITE 202
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402
Practice Address - Country:US
Practice Address - Phone:505-325-4101
Practice Address - Fax:505-327-7947
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA141237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1540653Medicaid