Provider Demographics
NPI:1003078809
Name:LAWRENCE-DEDERICH, SUSAN (MACCCSLP/L,TSHH)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:LAWRENCE-DEDERICH
Suffix:
Gender:F
Credentials:MACCCSLP/L,TSHH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 LAKEFRONT BLVD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-4325
Mailing Address - Country:US
Mailing Address - Phone:716-853-4733
Mailing Address - Fax:
Practice Address - Street 1:299 LAKEFRONT BLVD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-4325
Practice Address - Country:US
Practice Address - Phone:716-853-4733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05586-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist