Provider Demographics
NPI:1912908211
Name:SHOCKLEY, SUZANNE (AUD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:
Last Name:SHOCKLEY
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 1:6770 W KILGORE AVE
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47396-9108
Mailing Address - Country:US
Mailing Address - Phone:765-759-9788
Mailing Address - Fax:765-759-9783
Practice Address - Street 1:6770 W KILGORE AVE
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:IN
Practice Address - Zip Code:47396-9108
Practice Address - Country:US
Practice Address - Phone:765-759-9788
Practice Address - Fax:765-759-9783
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23001414A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200260110AMedicaid
INS99395Medicare UPIN
IN200260110AMedicaid