Provider Demographics
NPI:1659635688
Name:BICKLINE, SUSAN MARY (SLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARY
Last Name:BICKLINE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9515 HOLY CROSS LN
Mailing Address - Street 2:BOX 99
Mailing Address - City:BREESE
Mailing Address - State:IL
Mailing Address - Zip Code:62230-3618
Mailing Address - Country:US
Mailing Address - Phone:618-526-4511
Mailing Address - Fax:618-526-2855
Practice Address - Street 1:9515 HOLY CROSS LN
Practice Address - Street 2:BOX 99
Practice Address - City:BREESE
Practice Address - State:IL
Practice Address - Zip Code:62230-3618
Practice Address - Country:US
Practice Address - Phone:618-526-4511
Practice Address - Fax:618-526-2855
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146003579235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist