Provider Demographics
NPI:1154462901
Name:GISLASON, SUSAN SHERFIELD (MA CCC SLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:SHERFIELD
Last Name:GISLASON
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:PO BOX 11220
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28404-1220
Mailing Address - Country:US
Mailing Address - Phone:910-232-5267
Mailing Address - Fax:910-686-8225
Practice Address - Street 1:7347 BRIGHT LEAF RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-7116
Practice Address - Country:US
Practice Address - Phone:910-232-5267
Practice Address - Fax:910-686-8225
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6309235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412508Medicaid