Provider Demographics
NPI:1225186778
Name:WITT, SUSAN BEASTROM (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BEASTROM
Last Name:WITT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-4921
Mailing Address - Country:US
Mailing Address - Phone:847-724-8581
Mailing Address - Fax:
Practice Address - Street 1:322 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-4921
Practice Address - Country:US
Practice Address - Phone:847-724-8581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist