Provider Demographics
NPI:1245454958
Name:BLAKEMORE, SUE ELLEN (MNS , CCC)
Entity type:Individual
Prefix:MS
First Name:SUE
Middle Name:ELLEN
Last Name:BLAKEMORE
Suffix:
Gender:F
Credentials:MNS , CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14052 N 14TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-4433
Mailing Address - Country:US
Mailing Address - Phone:602-441-3240
Mailing Address - Fax:
Practice Address - Street 1:4650 W. SWEETWATER
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304
Practice Address - Country:US
Practice Address - Phone:602-347-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0321235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist