Provider Demographics
NPI:1265575278
Name:LOPEZ, SUSAN MARIE (SLP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:LOPEZ
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 1:2924 BROOK RD
Mailing Address - Street 2:CHILDREN'S HOSPITAL CREDENTIALING DEPT
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-1215
Mailing Address - Country:US
Mailing Address - Phone:804-321-7474
Mailing Address - Fax:804-321-2728
Practice Address - Street 1:10530 SPOTSYLVANIA AVE
Practice Address - Street 2:CHILDREN'S HOSPITAL THERAPY CENTER SUITE 102
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-0000
Practice Address - Country:US
Practice Address - Phone:540-891-4485
Practice Address - Fax:540-890-4486
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202001904235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004909976Medicaid