Provider Demographics
NPI:1417403908
Name:SUSTAR, KELLY ANNE BURKE
Entity Type:Individual
Prefix:MRS
First Name:KELLY ANNE
Middle Name:BURKE
Last Name:SUSTAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2672 BELVOIR BLVD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-1924
Mailing Address - Country:US
Mailing Address - Phone:216-650-0420
Mailing Address - Fax:
Practice Address - Street 1:5044 MAYFIELD RD
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-2605
Practice Address - Country:US
Practice Address - Phone:216-691-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP10182235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist