Provider Demographics
NPI:1497060057
Name:LEORZA, SUSAN (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LEORZA
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SYCAMORE CIR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-3411
Mailing Address - Country:US
Mailing Address - Phone:386-677-6153
Mailing Address - Fax:
Practice Address - Street 1:397 PALM COAST PKWY SW
Practice Address - Street 2:SUITE 1
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4776
Practice Address - Country:US
Practice Address - Phone:386-793-8120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA1714235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA1714OtherSTATE LICENSURE