Provider Demographics
NPI:1013257203
Name:BENGTSON, SUSAN M (MACCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:BENGTSON
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17174 SOCKEYE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-9168
Mailing Address - Country:US
Mailing Address - Phone:360-422-6263
Mailing Address - Fax:
Practice Address - Street 1:920 S 2ND ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-4205
Practice Address - Country:US
Practice Address - Phone:360-428-6141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL 60327061235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist