Provider Demographics
NPI:1093984908
Name:PRENDERGAST, SUSAN GEORGIA (PHD, CCC-A)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GEORGIA
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:PHD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SPEECH AND HEARNG CLINIC IL STATE UNIVERSITY
Mailing Address - Street 2:211 RACHEL COOPER HALL
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61790-4720
Mailing Address - Country:US
Mailing Address - Phone:309-438-2829
Mailing Address - Fax:309-438-5221
Practice Address - Street 1:SPEECH AND HEARNG CLINIC IL STATE UNIVERSITY
Practice Address - Street 2:211 RACHEL COOPER HALL
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61790-4720
Practice Address - Country:US
Practice Address - Phone:309-438-2829
Practice Address - Fax:309-438-5221
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist