Provider Demographics
NPI:1558408146
Name:ANDERSON, SUSAN J (AUD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2242 78TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-2125
Mailing Address - Country:US
Mailing Address - Phone:206-232-6337
Mailing Address - Fax:
Practice Address - Street 1:4131 15TH AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-6250
Practice Address - Country:US
Practice Address - Phone:206-543-1575
Practice Address - Fax:206-616-1185
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD00001069237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8401242Medicaid
WA640004388Medicare PIN
WAGAB16026Medicare PIN
WAG8872220Medicare PIN
WA8401242Medicaid
WAGAB28067Medicare PIN
WAGAB16025Medicare PIN