Provider Demographics
NPI:1235279605
Name:ROSE, SUSAN BOTTS (MS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BOTTS
Last Name:ROSE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1473 SW 4TH CT
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-7138
Mailing Address - Country:US
Mailing Address - Phone:561-317-1409
Mailing Address - Fax:
Practice Address - Street 1:1473 SW 4TH CT
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-7138
Practice Address - Country:US
Practice Address - Phone:561-317-1409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5279235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA5279OtherSTATE LICENSE NUMBER