Provider Demographics
NPI:1558375956
Name:WILSON, SUSAN D
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:D
Other - Last Name:SPITERI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 406153
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1876
Mailing Address - Country:US
Mailing Address - Phone:989-345-7550
Mailing Address - Fax:989-345-7590
Practice Address - Street 1:110 BEECH ST
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-8314
Practice Address - Country:US
Practice Address - Phone:989-362-8196
Practice Address - Fax:989-362-0967
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501003110237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1558375956Medicaid