Provider Demographics
NPI:1548402803
Name:WHITAKER, SUSAN E (MED CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:E
Last Name:WHITAKER
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 1:3624 OLD PETERSBURG RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2865
Mailing Address - Country:US
Mailing Address - Phone:706-364-4370
Mailing Address - Fax:
Practice Address - Street 1:3624 OLD PETERSBURG RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-2865
Practice Address - Country:US
Practice Address - Phone:706-364-4370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1031235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GASLP001031Medicaid