Provider Demographics
NPI:1316371990
Name:HERRMANN-EKSTAM, SUSAN ELIZABETH (MS, CCC-A, FAAA)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:HERRMANN-EKSTAM
Suffix:
Gender:F
Credentials:MS, CCC-A, FAAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3242 S NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7303
Mailing Address - Country:US
Mailing Address - Phone:417-889-5353
Mailing Address - Fax:417-889-5355
Practice Address - Street 1:3242 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7303
Practice Address - Country:US
Practice Address - Phone:417-889-5353
Practice Address - Fax:417-889-5355
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO120022231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist