Provider Demographics
NPI:1407233356
Name:WELLS, SUSAN C (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:C
Last Name:WELLS
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 1:4025 TAMPA RD STE 1106
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-3213
Mailing Address - Country:US
Mailing Address - Phone:888-974-7878
Mailing Address - Fax:717-635-3211
Practice Address - Street 1:1550 KILLINGSWORTH WAY
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-2175
Practice Address - Country:US
Practice Address - Phone:352-674-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA4266235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist