Provider Demographics
NPI:1992071633
Name:CLOUGH, SUSAN H (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:H
Last Name:CLOUGH
Suffix:
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 1:998 E 200 S
Mailing Address - Street 2:
Mailing Address - City:DECLO
Mailing Address - State:ID
Mailing Address - Zip Code:83323-5024
Mailing Address - Country:US
Mailing Address - Phone:208-677-6530
Mailing Address - Fax:208-677-6036
Practice Address - Street 1:1501 HILAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2688
Practice Address - Country:US
Practice Address - Phone:208-677-6530
Practice Address - Fax:208-677-6306
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1418235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist