Provider Demographics
NPI:1740265271
Name:CAMPBELL, SUZAN MARIE (SLP)
Entity type:Individual
Prefix:
First Name:SUZAN
Middle Name:MARIE
Last Name:CAMPBELL
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 1:1104 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-4412
Mailing Address - Country:US
Mailing Address - Phone:940-235-1000
Mailing Address - Fax:
Practice Address - Street 1:1005 MIDWESTERN PKWY
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76302-2211
Practice Address - Country:US
Practice Address - Phone:940-322-0771
Practice Address - Fax:940-766-4943
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100444235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100444OtherHUMANA ID #
TN125017OtherSUPERIOR ID #
TX0077279OtherBLUE LINK#
TX86857TOtherBCBS PROVIDER #