Provider Demographics
NPI:1881332492
Name:CHERTCOW, SUSANNA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:
Last Name:CHERTCOW
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 1:1356 FERENDINA DR
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-4724
Mailing Address - Country:US
Mailing Address - Phone:386-456-8547
Mailing Address - Fax:
Practice Address - Street 1:4875 PALM COAST PKWY NW UNIT 2
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3671
Practice Address - Country:US
Practice Address - Phone:386-446-9935
Practice Address - Fax:386-446-7777
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA16770235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA16770OtherHEALTHCARE LICENSE