Provider Demographics
NPI:1063781417
Name:THOMAS, SUSAN C (SLP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:THOMAS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 WINDSOR PATH
Mailing Address - Street 2:SUITE 3
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9617
Mailing Address - Country:US
Mailing Address - Phone:859-588-3709
Mailing Address - Fax:502-603-0622
Practice Address - Street 1:105 WINDSOR PATH
Practice Address - Street 2:SUITE 3
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9617
Practice Address - Country:US
Practice Address - Phone:859-588-3709
Practice Address - Fax:502-603-0622
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-14
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2753235Z00000X
KY140514235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50071615OtherPASSPORT
KY7100270890Medicaid
KY000000745845OtherANTHEM
KYK047021Medicare PIN