Provider Demographics
NPI:1255316212
Name:PRIM, SUSANNA GAIL (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:SUSANNA
Middle Name:GAIL
Last Name:PRIM
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
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Mailing Address - Street 1:5414 DONNELLY CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22151-1705
Mailing Address - Country:US
Mailing Address - Phone:703-323-1367
Mailing Address - Fax:
Practice Address - Street 1:6506 LOISDALE RD
Practice Address - Street 2:STE 300
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-1824
Practice Address - Country:US
Practice Address - Phone:703-924-4100
Practice Address - Fax:703-922-0638
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA2202004426235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist