Provider Demographics
NPI:1346204708
Name:WALTERS, SUSAN M (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:WALTERS
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 1:1301 ROLLING HILLS CT
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-9148
Mailing Address - Country:US
Mailing Address - Phone:704-787-0224
Mailing Address - Fax:
Practice Address - Street 1:1301 ROLLING HILLS CT
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-9148
Practice Address - Country:US
Practice Address - Phone:704-787-0224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7056235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412485Medicaid
NC141UKOtherNC BCBS