Provider Demographics
NPI:1063056968
Name:WOOTEN, SUSANNA ELEANOR (MSP-CCC,SLP)
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:ELEANOR
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:MSP-CCC,SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16147 LANCASTER HWY STE 130
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-2051
Mailing Address - Country:US
Mailing Address - Phone:704-307-9541
Mailing Address - Fax:704-540-1197
Practice Address - Street 1:16147 LANCASTER HWY STE 130
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-2051
Practice Address - Country:US
Practice Address - Phone:704-307-9541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13223235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNONE