Provider Demographics
NPI:1093201766
Name:WADE, SUSAN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4824 GLENMORGAN CT
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-6596
Mailing Address - Country:US
Mailing Address - Phone:571-278-1456
Mailing Address - Fax:
Practice Address - Street 1:THE CROSSINGS AT IRONBRIDGE
Practice Address - Street 2:6701 IRONBRIDGE PKWY
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831
Practice Address - Country:US
Practice Address - Phone:804-748-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003283235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist