Provider Demographics
NPI:1700910254
Name:ANDERSON, SUSAN (SLP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:ANDERSON
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 1:1700 MAE AVE SW
Mailing Address - Street 2:VALLE VISTA ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-2822
Mailing Address - Country:US
Mailing Address - Phone:505-836-7739
Mailing Address - Fax:
Practice Address - Street 1:1700 MAE AVE SW
Practice Address - Street 2:VALLE VISTA ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-2822
Practice Address - Country:US
Practice Address - Phone:505-836-7739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1293235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMJ 3881Medicaid