Provider Demographics
NPI:1760504070
Name:WATERS, SUSAN RAE (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:RAE
Last Name:WATERS
Suffix:
Gender:F
Credentials:MA CCC-SLP
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Other - First Name:
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Mailing Address - Street 1:3699 ALEXANDRIA PIKE
Mailing Address - Street 2:SUITE D
Mailing Address - City:COLD SPRING
Mailing Address - State:KY
Mailing Address - Zip Code:41076-1789
Mailing Address - Country:US
Mailing Address - Phone:859-572-0430
Mailing Address - Fax:859-572-0163
Practice Address - Street 1:3699 ALEXANDRIA PIKE
Practice Address - Street 2:SUITE D
Practice Address - City:COLD SPRING
Practice Address - State:KY
Practice Address - Zip Code:41076-1789
Practice Address - Country:US
Practice Address - Phone:859-572-0430
Practice Address - Fax:859-572-0163
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY136811235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist