Provider Demographics
NPI:1093850497
Name:COFFEY, SUSAN TAYLOR (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:TAYLOR
Last Name:COFFEY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 COLQUITT DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-3175
Mailing Address - Country:US
Mailing Address - Phone:910-793-0118
Mailing Address - Fax:
Practice Address - Street 1:224 COLQUITT DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-3175
Practice Address - Country:US
Practice Address - Phone:910-793-0118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6530235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6530OtherNC LICENSE NUMBER
NC12018222OtherASHA CERTIFICATION #
NC7412172Medicaid