Provider Demographics
NPI:1891727780
Name:HOLTON, SUSAN D (SLP, MA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:HOLTON
Suffix:
Gender:F
Credentials:SLP, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 CENTER PARK DR
Mailing Address - Street 2:SUITE 3060
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-2108
Mailing Address - Country:US
Mailing Address - Phone:865-966-8545
Mailing Address - Fax:865-966-3936
Practice Address - Street 1:187 GALLAHER RD
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-4721
Practice Address - Country:US
Practice Address - Phone:865-376-4620
Practice Address - Fax:865-376-1759
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3420235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4123469OtherBLUECROSS BLUESHIELD
TN5440741Medicaid