Provider Demographics
NPI:1508896697
Name:SUPSURA, SUSAN M (MSCCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:SUPSURA
Suffix:
Gender:F
Credentials:MSCCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 DEERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-6941
Mailing Address - Country:US
Mailing Address - Phone:803-548-2527
Mailing Address - Fax:
Practice Address - Street 1:2233 DEERFIELD DR
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-6941
Practice Address - Country:US
Practice Address - Phone:803-548-2527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3966235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0719Medicaid