Provider Demographics
NPI:1336113737
Name:WHITAKER, SUSAN E (MA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 496084
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96049-6084
Mailing Address - Country:US
Mailing Address - Phone:530-241-0473
Mailing Address - Fax:530-229-3703
Practice Address - Street 1:2208 PARK MARINA DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2111
Practice Address - Country:US
Practice Address - Phone:530-244-0263
Practice Address - Fax:530-247-0688
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP3559235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ819472Medicaid