Provider Demographics
NPI:1619251774
Name:NISAR, SUFIA SHAISTA (MSC, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SUFIA
Middle Name:SHAISTA
Last Name:NISAR
Suffix:
Gender:F
Credentials:MSC, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6475 PARK POINTE CT
Mailing Address - Street 2:
Mailing Address - City:PEPPER PIKE
Mailing Address - State:OH
Mailing Address - Zip Code:44124-5395
Mailing Address - Country:US
Mailing Address - Phone:732-476-4334
Mailing Address - Fax:
Practice Address - Street 1:6475 PARK POINTE CT
Practice Address - Street 2:
Practice Address - City:PEPPER PIKE
Practice Address - State:OH
Practice Address - Zip Code:44124-5395
Practice Address - Country:US
Practice Address - Phone:732-476-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-10166235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1564187Medicaid
OH366518Medicare PIN