Provider Demographics
NPI:1184934093
Name:AVALOS, SUSANA ELIZABETH (SLP)
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:ELIZABETH
Last Name:AVALOS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65-41 SAUNDERS ST
Mailing Address - Street 2:APT 1E
Mailing Address - City:REGO PARK, QUEENS
Mailing Address - State:NY
Mailing Address - Zip Code:11374
Mailing Address - Country:US
Mailing Address - Phone:226-201-0608
Mailing Address - Fax:
Practice Address - Street 1:630 GRAND ST
Practice Address - Street 2:APT 2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-4804
Practice Address - Country:US
Practice Address - Phone:212-470-0911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-13
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019283235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist