Provider Demographics
NPI:1083997522
Name:SMITH, SUZANNE D (SLP)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:D
Last Name:SMITH
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 1:9579 VOCATIONAL DRIVE
Mailing Address - Street 2:COOPERS CAMPUS
Mailing Address - City:PAINTED POST
Mailing Address - State:NY
Mailing Address - Zip Code:14870
Mailing Address - Country:US
Mailing Address - Phone:607-776-6788
Mailing Address - Fax:607-654-2304
Practice Address - Street 1:9579 VOCATIONAL DR
Practice Address - Street 2:
Practice Address - City:PAINTED POST
Practice Address - State:NY
Practice Address - Zip Code:14870-9043
Practice Address - Country:US
Practice Address - Phone:607-962-3175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2014-01-17
Deactivation Date:2011-10-31
Deactivation Code:
Reactivation Date:2013-10-23
Provider Licenses
StateLicense IDTaxonomies
NY011476-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY011476-1OtherNYS LICENSE