Provider Demographics
NPI:1659739001
Name:MATHEW, CHINNU SUSAN
Entity Type:Individual
Prefix:
First Name:CHINNU
Middle Name:SUSAN
Last Name:MATHEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 WOODBERRY DR
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-4061
Mailing Address - Country:US
Mailing Address - Phone:972-814-1476
Mailing Address - Fax:
Practice Address - Street 1:10610 METRIC DR
Practice Address - Street 2:SUITE 101
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-5581
Practice Address - Country:US
Practice Address - Phone:214-221-4405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-31
Last Update Date:2016-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX391092355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant