Provider Demographics
NPI:1073745097
Name:GREEN, SUZANNE KATHERINE (SLP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:KATHERINE
Last Name:GREEN
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 1:48 MARSH RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-9434
Mailing Address - Country:US
Mailing Address - Phone:607-351-1006
Mailing Address - Fax:
Practice Address - Street 1:48 MARSH RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-9434
Practice Address - Country:US
Practice Address - Phone:607-351-1006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008914-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist