Provider Demographics
NPI:1831262021
Name:CARNEOL, SUSAN O (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:O
Last Name:CARNEOL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10303 N PORT WASHINGTON RD STE 203
Mailing Address - Street 2:NORTH SHORE CENTER, LLC
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5760
Mailing Address - Country:US
Mailing Address - Phone:262-241-5955
Mailing Address - Fax:
Practice Address - Street 1:10303 N PORT WASHINGTON RD STE 203
Practice Address - Street 2:NORTH SHORE CENTER LLC
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5760
Practice Address - Country:US
Practice Address - Phone:262-241-5955
Practice Address - Fax:262-241-5926
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI448154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42555000Medicaid