Provider Demographics
NPI:1609274802
Name:SUNDBERG, MARY SUSAN (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SUSAN
Last Name:SUNDBERG
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6700 ANTIOCH RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MERRIAM
Mailing Address - State:KS
Mailing Address - Zip Code:66204-1497
Mailing Address - Country:US
Mailing Address - Phone:888-652-9225
Mailing Address - Fax:
Practice Address - Street 1:6700 ANTIOCH RD
Practice Address - Street 2:SUITE 120
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204-1497
Practice Address - Country:US
Practice Address - Phone:888-652-9225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-21
Last Update Date:2014-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS584235Z00000X
MO2007006503235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist