Provider Demographics
NPI:1497129464
Name:LOOMIS, SUSAN ROBERTA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ROBERTA
Last Name:LOOMIS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10440 SHAKER DR STE 209
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-2339
Mailing Address - Country:US
Mailing Address - Phone:443-691-6415
Mailing Address - Fax:
Practice Address - Street 1:10440 SHAKER DR STE 209
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2339
Practice Address - Country:US
Practice Address - Phone:443-691-6415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-13
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01910235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist