Provider Demographics
NPI:1801803192
Name:GORE, SUSAN EVANS (AUD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:EVANS
Last Name:GORE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4868
Mailing Address - Street 2:
Mailing Address - City:CALABASH
Mailing Address - State:NC
Mailing Address - Zip Code:28467-9820
Mailing Address - Country:US
Mailing Address - Phone:910-755-2428
Mailing Address - Fax:910-755-2435
Practice Address - Street 1:2298 OCEAN HWY W
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4024
Practice Address - Country:US
Practice Address - Phone:910-755-2428
Practice Address - Fax:910-755-2435
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1102231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3404235Medicaid