Provider Demographics
NPI:1922577147
Name:FREDERICKSON, SUZANNE A (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:A
Last Name:FREDERICKSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:A
Other - Last Name:STOCKTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:156 NORTH MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525
Mailing Address - Country:US
Mailing Address - Phone:706-212-0390
Mailing Address - Fax:706-960-9209
Practice Address - Street 1:HIGHLANDS INTERNAL MEDICINE, PC
Practice Address - Street 2:156 NORTH MAIN ST
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525
Practice Address - Country:US
Practice Address - Phone:706-212-0390
Practice Address - Fax:706-960-9209
Is Sole Proprietor?:No
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004550235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist