Provider Demographics
NPI:1023154473
Name:PETTIJOHN, SUSAN P (MA, CCC, SLP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:P
Last Name:PETTIJOHN
Suffix:
Gender:F
Credentials:MA, CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 EVES DR
Mailing Address - Street 2:SUITE 160
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3135
Mailing Address - Country:US
Mailing Address - Phone:856-985-9257
Mailing Address - Fax:856-985-7943
Practice Address - Street 1:5 EVES DR
Practice Address - Street 2:SUITE 160
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3135
Practice Address - Country:US
Practice Address - Phone:856-985-9257
Practice Address - Fax:856-985-7943
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJYS00867235Z00000X
PASL005294L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist