Provider Demographics
NPI:1669564282
Name:DOHERTY, SUSANNAH C (SLP)
Entity type:Individual
Prefix:MRS
First Name:SUSANNAH
Middle Name:C
Last Name:DOHERTY
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 1:1538 CHARON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-9202
Mailing Address - Country:US
Mailing Address - Phone:904-387-0986
Mailing Address - Fax:904-388-6235
Practice Address - Street 1:12276 SAN JOSE BLVD.
Practice Address - Street 2:SUITE 508
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8628
Practice Address - Country:US
Practice Address - Phone:904-886-3228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA3951235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist