Provider Demographics
NPI:1245548528
Name:PURVIANCE, SUSAN (MSED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PURVIANCE
Suffix:
Gender:
Credentials:MSED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 WAXHAW PROFESSIONAL PARK DR STE A
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-5018
Mailing Address - Country:US
Mailing Address - Phone:704-627-4027
Mailing Address - Fax:704-684-4644
Practice Address - Street 1:105 WAXHAW PROFESSIONAL PARK DR STE A
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-5018
Practice Address - Country:US
Practice Address - Phone:704-627-4027
Practice Address - Fax:704-684-4644
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-20
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9156235Z00000X
NC13215235Z00000X
NY015604-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist