Provider Demographics
NPI:1306944681
Name:CARPENTER, SUSAN SULLIVAN (MACCC SLP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:SULLIVAN
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:MACCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4171 WESTPORT RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-2739
Mailing Address - Country:US
Mailing Address - Phone:502-896-8868
Mailing Address - Fax:502-895-8794
Practice Address - Street 1:4171 WESTPORT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-2739
Practice Address - Country:US
Practice Address - Phone:502-896-8868
Practice Address - Fax:502-895-8794
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0328235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000048974OtherANTHEM ID