Provider Demographics
NPI:1215373287
Name:YOUNGDALE, SUSAN (SLP-MA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:YOUNGDALE
Suffix:
Gender:F
Credentials:SLP-MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1194 PACIFIC ST.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3342
Mailing Address - Country:US
Mailing Address - Phone:805-234-1055
Mailing Address - Fax:805-416-2422
Practice Address - Street 1:1194 PACIFIC ST.
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3342
Practice Address - Country:US
Practice Address - Phone:805-234-1055
Practice Address - Fax:805-416-2422
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-17
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 8885235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist