Provider Demographics
NPI:1063841682
Name:MOLLMAN, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MOLLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:J
Other - Last Name:LOTHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:410 SHANNON DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3353
Mailing Address - Country:US
Mailing Address - Phone:859-653-0284
Mailing Address - Fax:
Practice Address - Street 1:410 SHANNON DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3353
Practice Address - Country:US
Practice Address - Phone:859-653-0284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2168235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist