Provider Demographics
NPI:1154659761
Name:DRIEFKE, SUSAN M
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:DRIEFKE
Suffix:
Gender:F
Credentials:
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 29
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-0029
Mailing Address - Country:US
Mailing Address - Phone:608-524-7903
Mailing Address - Fax:608-524-7977
Practice Address - Street 1:505 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-2183
Practice Address - Country:US
Practice Address - Phone:608-524-7903
Practice Address - Fax:608-524-7977
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI03K00000X103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst