Provider Demographics
NPI:1093798498
Name:WALSH, SUSAN K (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:K
Last Name:WALSH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1526
Mailing Address - Country:US
Mailing Address - Phone:262-637-8888
Mailing Address - Fax:262-637-0695
Practice Address - Street 1:2021 N 60TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-1641
Practice Address - Country:US
Practice Address - Phone:414-771-2881
Practice Address - Fax:414-771-1674
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2850-1231041C0700X
WI106H00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39677500Medicaid
WI39677500Medicaid