Provider Demographics
NPI:1699912980
Name:VANESSEN, SUSAN (MA,CCC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:VANESSEN
Suffix:
Gender:F
Credentials:MA,CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4590 DEERWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-1343
Mailing Address - Country:US
Mailing Address - Phone:515-201-3551
Mailing Address - Fax:
Practice Address - Street 1:2555 BERKSHIRE PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-4646
Practice Address - Country:US
Practice Address - Phone:515-987-8835
Practice Address - Fax:515-987-4637
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00073235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist