Provider Demographics
NPI:1164716098
Name:WISNIEWSKI, SUSAN EILEEN (MS CCC-SLP/L)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:EILEEN
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:MS CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SHAWNEE RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-3583
Mailing Address - Country:US
Mailing Address - Phone:419-999-2010
Mailing Address - Fax:419-999-6284
Practice Address - Street 1:640 WORTH ST
Practice Address - Street 2:
Practice Address - City:CORRY
Practice Address - State:PA
Practice Address - Zip Code:16407-8515
Practice Address - Country:US
Practice Address - Phone:814-664-9606
Practice Address - Fax:814-665-0036
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL005451L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA22Medicare UPIN