Provider Demographics
NPI:1578031019
Name:HALL, SUSAN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 PRAIRIE PASS
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4247
Mailing Address - Country:US
Mailing Address - Phone:512-521-1206
Mailing Address - Fax:
Practice Address - Street 1:4405 EVANS TO LOCKS RD STE C
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3737
Practice Address - Country:US
Practice Address - Phone:706-854-1598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASP010392235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist