Basic Information
| Provider Information | |||||||||
| NPI: | 1568798122 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FASS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | LANZARA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 VERNEY DR | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030475000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035473311 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 VERNEY DR | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030475000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035473311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2009 | ||||||||
| LastUpdateDate: | 02/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 1019 | NH | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 3076438 | 05 | NH | MEDICAID | 1019 | 01 | NH | SLP LICENSE | OTHER |