Provider Demographics
NPI:1063836930
Name:STICKEL, SUSAN (SLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:STICKEL
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 1:40 HEATHERGLEN CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-1583
Mailing Address - Country:US
Mailing Address - Phone:937-271-9308
Mailing Address - Fax:
Practice Address - Street 1:1 DONHAM PLZ
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-1932
Practice Address - Country:US
Practice Address - Phone:513-422-0713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.P.1232235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist