Basic Information
| Provider Information | |||||||||
| NPI: | 1932492097 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLTHURST | ||||||||
| FirstName: | SUZANN | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHELPS | ||||||||
| OtherFirstName: | SUZANN | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2988 COURT ST | ||||||||
| Address2: | |||||||||
| City: | PEKIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615546229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093535940 | ||||||||
| FaxNumber: | 3093531654 | ||||||||
| Practice Location | |||||||||
| Address1: | 2988 COURT ST | ||||||||
| Address2: | |||||||||
| City: | PEKIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615546229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093535940 | ||||||||
| FaxNumber: | 3093531654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2011 | ||||||||
| LastUpdateDate: | 01/27/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 146009971 | IL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 537460031 | 01 | IL | MEDICARE PTAN | OTHER | P00991695 | 01 | IL | RR MEDICARE | OTHER |