Provider Demographics
NPI:1215083233
Name:FITZGERALD, SUSAN MARY (MA CCCSLP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARY
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:MA CCCSLP
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:FITZGERALD
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA CCCSLP
Mailing Address - Street 1:7901 YUCCA DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653
Mailing Address - Country:US
Mailing Address - Phone:727-845-4435
Mailing Address - Fax:727-841-0190
Practice Address - Street 1:7901 YUCCA DR
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653
Practice Address - Country:US
Practice Address - Phone:727-845-4435
Practice Address - Fax:727-841-0190
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2452235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA2452OtherSLP LICENSE