Provider Demographics
NPI:1720617418
Name:FISHLOVE, SUSANNA RITACCA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SUSANNA
Middle Name:RITACCA
Last Name:FISHLOVE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 LAKE SUMMIT CT
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-4010
Mailing Address - Country:US
Mailing Address - Phone:612-368-7474
Mailing Address - Fax:
Practice Address - Street 1:535 LAKE SUMMIT CT
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-4010
Practice Address - Country:US
Practice Address - Phone:954-707-0829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10285235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist