Provider Demographics
NPI:1811204860
Name:EIDSON, SUE ANN (PH D)
Entity Type:Individual
Prefix:DR
First Name:SUE
Middle Name:ANN
Last Name:EIDSON
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 FLORIDA ST
Mailing Address - Street 2:#2
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1370
Mailing Address - Country:US
Mailing Address - Phone:352-214-5007
Mailing Address - Fax:
Practice Address - Street 1:620 FLORIDA ST
Practice Address - Street 2:#2
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1370
Practice Address - Country:US
Practice Address - Phone:352-214-5007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA689235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist