Basic Information
| Provider Information | |||||||||
| NPI: | 1942465976 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIEMCZYK | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURNER | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | H | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S., CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13900 HULL STREET RD | ||||||||
| Address2: | |||||||||
| City: | MIDLOTHIAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231122004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046398788 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13900 HULL STREET RD | ||||||||
| Address2: | |||||||||
| City: | MIDLOTHIAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231122004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046398788 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2008 | ||||||||
| LastUpdateDate: | 04/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2202004214 | VA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 004978382 | 05 | VA | MEDICAID |