Provider Demographics
NPI:1821348921
Name:EISEN, SUSAN HARRIET (MED)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:HARRIET
Last Name:EISEN
Suffix:
Gender:F
Credentials:MED
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 1224
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:FL
Mailing Address - Zip Code:32640-1224
Mailing Address - Country:US
Mailing Address - Phone:352-481-4516
Mailing Address - Fax:
Practice Address - Street 1:6700 NW 10TH PL
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4213
Practice Address - Country:US
Practice Address - Phone:352-331-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-16
Last Update Date:2012-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 635235Z00000X
CA5818235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist