Provider Demographics
NPI:1659688869
Name:MARDJETKO, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MARDJETKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7927 STATE ROAD 52
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667
Mailing Address - Country:US
Mailing Address - Phone:727-378-8586
Mailing Address - Fax:727-378-8587
Practice Address - Street 1:7927 STATE ROAD 52
Practice Address - Street 2:ATRIA BAYPOINT VILLAGE
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667
Practice Address - Country:US
Practice Address - Phone:727-378-8586
Practice Address - Fax:727-378-8587
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2502235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist