Provider Demographics
NPI:1275500829
Name:DETELS, SUSAN L (AUD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:L
Last Name:DETELS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 W AZALEA AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-1894
Mailing Address - Country:US
Mailing Address - Phone:541-688-9194
Mailing Address - Fax:
Practice Address - Street 1:360 S GARDEN WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-8173
Practice Address - Country:US
Practice Address - Phone:541-349-9333
Practice Address - Fax:541-349-0082
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21293237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR113899Medicaid
OR00WCKBQGMedicare ID - Type Unspecified