Provider Demographics
NPI:1558684142
Name:SUSO, KEN S (BSC,HIS,OTO TECH)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:S
Last Name:SUSO
Suffix:
Gender:M
Credentials:BSC,HIS,OTO TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7226 HILLSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:SACHSE
Mailing Address - State:TX
Mailing Address - Zip Code:75048-5646
Mailing Address - Country:US
Mailing Address - Phone:469-361-1257
Mailing Address - Fax:
Practice Address - Street 1:5250 HIGHWAY 78
Practice Address - Street 2:STE 750-453
Practice Address - City:SACHSE
Practice Address - State:TX
Practice Address - Zip Code:75048-4252
Practice Address - Country:US
Practice Address - Phone:469-879-8834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80384237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist