Provider Demographics
NPI:1922584200
Name:KIM, SUSAN (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 W TAFT RD STE 202
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-2806
Mailing Address - Country:US
Mailing Address - Phone:315-216-0993
Mailing Address - Fax:
Practice Address - Street 1:2949 FOX CHASE LN
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4400
Practice Address - Country:US
Practice Address - Phone:804-430-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08829235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist