Provider Demographics
NPI:1376586842
Name:MOYER, SUSIE ROBERTS (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SUSIE
Middle Name:ROBERTS
Last Name:MOYER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 WATSON SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-3622
Mailing Address - Country:US
Mailing Address - Phone:706-255-1039
Mailing Address - Fax:706-369-4492
Practice Address - Street 1:2440 WATSON SPRINGS RD
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-3622
Practice Address - Country:US
Practice Address - Phone:706-255-1039
Practice Address - Fax:706-369-4492
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003326235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000761153AMedicaid