Provider Demographics
NPI:1962651208
Name:PORT, SUSAN B (MSCCCSLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:PORT
Suffix:
Gender:F
Credentials:MSCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 ONEIDA AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11509-1425
Mailing Address - Country:US
Mailing Address - Phone:516-410-3285
Mailing Address - Fax:
Practice Address - Street 1:82 ONEIDA AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC BEACH
Practice Address - State:NY
Practice Address - Zip Code:11509-1425
Practice Address - Country:US
Practice Address - Phone:516-410-3285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003086-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist