Provider Demographics
NPI:1932485844
Name:ERDIGE HOLZ, SUSAN
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:ERDIGE HOLZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 OUTER STATE STREET
Mailing Address - Street 2:BOCES
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-3256
Mailing Address - Country:US
Mailing Address - Phone:315-386-4504
Mailing Address - Fax:
Practice Address - Street 1:139 OUTER STATE STREET
Practice Address - Street 2:BOCES
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-3256
Practice Address - Country:US
Practice Address - Phone:315-386-4504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020358-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00729673OtherASHA
NY020358-1OtherNYSTATE LICENSURE