Provider Demographics
NPI:1124007349
Name:MCANINCH, SUSAN J (MSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:MCANINCH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-2546
Mailing Address - Country:US
Mailing Address - Phone:920-746-0162
Mailing Address - Fax:920-746-0140
Practice Address - Street 1:20 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-2546
Practice Address - Country:US
Practice Address - Phone:920-746-0162
Practice Address - Fax:920-746-0140
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6742-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43569800Medicaid
WI43569800Medicaid