Provider Demographics
NPI:1124007455
Name:WESTFALL, SUSAN LEE (CCC-A)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEE
Last Name:WESTFALL
Suffix:
Gender:F
Credentials: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:PO BOX 625
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:IN
Mailing Address - Zip Code:47446-0625
Mailing Address - Country:US
Mailing Address - Phone:812-583-0285
Mailing Address - Fax:
Practice Address - Street 1:775 WAUKEGAN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-4342
Practice Address - Country:US
Practice Address - Phone:800-317-0711
Practice Address - Fax:800-434-7113
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002206A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000220069OtherANTHEM
IN200130000Medicaid
IN090350AMedicare PIN
IN000000220069OtherANTHEM