Provider Demographics
NPI:1366599565
Name:BLACK, SUSAN E SR (MS,CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:E
Last Name:BLACK
Suffix:SR
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 LAKEVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:VA
Mailing Address - Zip Code:22508-5664
Mailing Address - Country:US
Mailing Address - Phone:540-972-9606
Mailing Address - Fax:
Practice Address - Street 1:3420 LAKEVIEW PKWY
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:VA
Practice Address - Zip Code:22508-5664
Practice Address - Country:US
Practice Address - Phone:540-972-9606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2002202317235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist