Provider Demographics
NPI:1306109715
Name:BEDWELL, SUSAN TRACY (MS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:TRACY
Last Name:BEDWELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:TRACY
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:1708 OTTERDALE RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-6914
Mailing Address - Country:US
Mailing Address - Phone:804-402-4254
Mailing Address - Fax:
Practice Address - Street 1:1708 OTTERDALE RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-6914
Practice Address - Country:US
Practice Address - Phone:804-402-4254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004156235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist