Provider Demographics
NPI:1063529956
Name:PETERSON, SUSIE BARTOLOME (CSCD CCC-SLP)
Entity type:Individual
Prefix:DR
First Name:SUSIE
Middle Name:BARTOLOME
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CSCD CCC-SLP
Other - Prefix:DR
Other - First Name:SUSIE
Other - Middle Name:J
Other - Last Name:BARTOLOME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:677 ALA MOANA BLVD STE 1001
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-5408
Mailing Address - Country:US
Mailing Address - Phone:808-469-4900
Mailing Address - Fax:808-536-7315
Practice Address - Street 1:677 ALA MOANA BLVD STE 625
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-5415
Practice Address - Country:US
Practice Address - Phone:808-692-1580
Practice Address - Fax:808-566-6292
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HISP-1826235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist