Provider Demographics
NPI:1790297653
Name:WISNIEWSKI, SUSAN MARIE
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:WISNIEWSKI
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 1:2900 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1631
Mailing Address - Country:US
Mailing Address - Phone:630-955-8037
Mailing Address - Fax:
Practice Address - Street 1:2900 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1631
Practice Address - Country:US
Practice Address - Phone:630-955-8037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146001836235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist