Provider Demographics
NPI:1225071186
Name:LONG, SUSAN M (MS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:LONG
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:W256N9267 TOMAHAWK DR
Mailing Address - Street 2:
Mailing Address - City:SUSSEX
Mailing Address - State:WI
Mailing Address - Zip Code:53089-1049
Mailing Address - Country:US
Mailing Address - Phone:414-266-2997
Mailing Address - Fax:414-266-6189
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3518
Practice Address - Country:US
Practice Address - Phone:414-266-2997
Practice Address - Fax:414-266-6189
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI436156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI436156OtherAUDIOLOGY STATE LICENSE
WI41148900Medicaid