Provider Demographics
NPI:1437573490
Name:BLECK, SUSAN
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:BLECK
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 1:6451 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4109
Mailing Address - Country:US
Mailing Address - Phone:440-257-9863
Mailing Address - Fax:
Practice Address - Street 1:6451 CENTER ST
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4109
Practice Address - Country:US
Practice Address - Phone:440-257-9863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP 3782235Z00000X
OHCL1009904235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCL1009904OtherOHIO DEPARTMENT OF EDUCATION
OHSP 3782OtherOHIO BOARD OF SPEECH PATHOLOGY AND AUDIOLOGY