Provider Demographics
NPI:1194846311
Name:NIELSEN, SUZETTE (SLP-CCC, MCD,MED)
Entity Type:Individual
Prefix:
First Name:SUZETTE
Middle Name:
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:SLP-CCC, MCD,MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1872
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-1872
Mailing Address - Country:US
Mailing Address - Phone:936-827-6469
Mailing Address - Fax:
Practice Address - Street 1:981 ARBOR WAY
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77303
Practice Address - Country:US
Practice Address - Phone:936-827-6469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19612235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171716701Medicaid