Provider Demographics
NPI:1568782985
Name:SUSAN E WHITAKER SHASTA SPEECH & LANGUAGE
Entity Type:Organization
Organization Name:SUSAN E WHITAKER SHASTA SPEECH & LANGUAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:SP
Authorized Official - Phone:530-244-0263
Mailing Address - Street 1:PO BOX 496084
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96049-6084
Mailing Address - Country:US
Mailing Address - Phone:530-244-0263
Mailing Address - Fax:530-247-0688
Practice Address - Street 1:2208 PARK MARINA DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2111
Practice Address - Country:US
Practice Address - Phone:530-244-0263
Practice Address - Fax:530-247-0688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-08
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP3559235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2009-0001238OtherFICTITITIOUS BUSINESS NAME