Provider Demographics
NPI:1164977930
Name:PIKE, SUSAN R (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:PIKE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 MINERAL POINT CT
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-3242
Mailing Address - Country:US
Mailing Address - Phone:608-436-3013
Mailing Address - Fax:
Practice Address - Street 1:402 MINERAL POINT CT
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-3242
Practice Address - Country:US
Practice Address - Phone:608-436-3013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI794-154235Z00000X
OR15458235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist