Provider Demographics
NPI:1598802795
Name:SUSTAD, JOSEPHINE ROSE (MA,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JOSEPHINE
Middle Name:ROSE
Last Name:SUSTAD
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 1:2598 ORR ST
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-4744
Mailing Address - Country:US
Mailing Address - Phone:516-623-2004
Mailing Address - Fax:
Practice Address - Street 1:300 GARDEN CITY PLZ
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-3302
Practice Address - Country:US
Practice Address - Phone:516-747-9030
Practice Address - Fax:516-877-0998
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005199235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist