Provider Demographics
NPI:1013451475
Name:BAHADORI, SUSAN (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BAHADORI
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 1:341 HIGHLAND AVE # 1
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-4510
Mailing Address - Country:US
Mailing Address - Phone:301-802-8342
Mailing Address - Fax:
Practice Address - Street 1:341 HIGHLAND AVE # 1
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-4510
Practice Address - Country:US
Practice Address - Phone:301-802-8342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP2317235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist