Provider Demographics
NPI:1134684848
Name:SUSKI, SUSAN (CSAC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SUSKI
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:KESHENA
Mailing Address - State:WI
Mailing Address - Zip Code:54135-0280
Mailing Address - Country:US
Mailing Address - Phone:715-799-3861
Mailing Address - Fax:715-799-3517
Practice Address - Street 1:W3272 WOLF RIVER DR
Practice Address - Street 2:
Practice Address - City:KESHENA
Practice Address - State:WI
Practice Address - Zip Code:54135-9202
Practice Address - Country:US
Practice Address - Phone:715-799-3861
Practice Address - Fax:715-799-3517
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10865101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100086054Medicaid