Provider Demographics
NPI:1972746634
Name:ZIMMERMAN, SUSAN MARY (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARY
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:MA 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:PO BOX 333
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:ME
Mailing Address - Zip Code:04950-0333
Mailing Address - Country:US
Mailing Address - Phone:207-696-8011
Mailing Address - Fax:
Practice Address - Street 1:144 HIGH ST STE 2
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938-1946
Practice Address - Country:US
Practice Address - Phone:207-778-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-10
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP602235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2175OtherSTATE OF SOUTH CAROLINA SPEECH PATHOLOGY LICENSE
00498220OtherASHA MEMBERSHIP NUMBER
MESP602OtherSATE OF MAINE SPEECH PATHOLOGY LICENSE