Provider Demographics
NPI:1881971430
Name:AGNEW, SUSAN MARIE (MSCCCSLP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:AGNEW
Suffix:
Gender:F
Credentials:MSCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9257 POTTER HILL RD
Mailing Address - Street 2:
Mailing Address - City:CATTARAUGUS
Mailing Address - State:NY
Mailing Address - Zip Code:14719-9602
Mailing Address - Country:US
Mailing Address - Phone:716-257-5246
Mailing Address - Fax:
Practice Address - Street 1:4460 BAY VIEW RD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-1335
Practice Address - Country:US
Practice Address - Phone:716-926-1740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006535235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01390945Medicaid