Provider Demographics
NPI:1750687604
Name:ROSE, SUSAN A (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:ROSE
Suffix:
Gender:F
Credentials: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:PO BOX 1911
Mailing Address - Street 2:
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-1911
Mailing Address - Country:US
Mailing Address - Phone:804-435-0758
Mailing Address - Fax:804-435-7226
Practice Address - Street 1:45 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:KILMARNOCK
Practice Address - State:VA
Practice Address - Zip Code:22482
Practice Address - Country:US
Practice Address - Phone:804-435-0758
Practice Address - Fax:804-435-7226
Is Sole Proprietor?:No
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202000579235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist