Provider Demographics
NPI:1740407824
Name:GRANDAW, SUSAN M
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:GRANDAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:R
Other - Last Name:MAGEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 323
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-0323
Mailing Address - Country:US
Mailing Address - Phone:315-386-4608
Mailing Address - Fax:
Practice Address - Street 1:139 STATE STREET RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-3504
Practice Address - Country:US
Practice Address - Phone:315-386-4504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009971235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist