Provider Demographics
NPI:1689750606
Name:PEDERSEN, SUSAN J (MSCCCSLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:MSCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PMB 401
Mailing Address - Street 2:201 EAST LYNDALE
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601
Mailing Address - Country:US
Mailing Address - Phone:406-442-3002
Mailing Address - Fax:406-442-2023
Practice Address - Street 1:1325 EUCLID AVE STE 6
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-2101
Practice Address - Country:US
Practice Address - Phone:406-442-3002
Practice Address - Fax:406-442-2023
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT943235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0533477Medicaid