Provider Demographics
NPI:1114428125
Name:LENZ, SUSAN ROBERTA (SPEECH PATHOLOGIST)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ROBERTA
Last Name:LENZ
Suffix:
Gender:F
Credentials:SPEECH PATHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 ARROWHEAD RD
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:MO
Mailing Address - Zip Code:65781-9235
Mailing Address - Country:US
Mailing Address - Phone:417-299-2176
Mailing Address - Fax:
Practice Address - Street 1:2800 S FORT AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-3495
Practice Address - Country:US
Practice Address - Phone:417-882-0035
Practice Address - Fax:417-882-0103
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-24
Last Update Date:2018-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01564235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist