Provider Demographics
NPI:1295060176
Name:LANDERMAN, SUE MERRY (MS, CCC/SLP)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:MERRY
Last Name:LANDERMAN
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:MERRY
Other - Last Name:BEGEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17923 ROCK DAM RD
Mailing Address - Street 2:
Mailing Address - City:ALVIN
Mailing Address - State:WI
Mailing Address - Zip Code:54542-9345
Mailing Address - Country:US
Mailing Address - Phone:725-545-3344
Mailing Address - Fax:
Practice Address - Street 1:5778 CHAPIN ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:WI
Practice Address - Zip Code:54121-9443
Practice Address - Country:US
Practice Address - Phone:715-528-4988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2042-154235Z00000X
FLSA 9812235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42-704-800Medicaid