Basic Information
Provider Information | |||||||||
NPI: | 1861648263 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DABO | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | LOUISE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S., CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HAUGHT | ||||||||
OtherFirstName: | SUSAN | ||||||||
OtherMiddleName: | LOUISE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.S., CCC-SLP | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 510 E. NORTH BROADWAY | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432144114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6142615482 | ||||||||
FaxNumber: | 6142635365 | ||||||||
Practice Location | |||||||||
Address1: | 510 E. NORTH BROADWAY | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432144114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6142635151 | ||||||||
FaxNumber: | 6142635365 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/18/2008 | ||||||||
LastUpdateDate: | 04/24/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SP 8302 | OH | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 0094740 | 05 | OH |   | MEDICAID |