Provider Demographics
NPI:1194029298
Name:ZUSSMAN, MIKE
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:
Last Name:ZUSSMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 N BAYSHORE DR STE A250
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4543
Mailing Address - Country:US
Mailing Address - Phone:414-962-6764
Mailing Address - Fax:414-962-6765
Practice Address - Street 1:5800 N BAYSHORE DR STE A250
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4543
Practice Address - Country:US
Practice Address - Phone:414-962-6764
Practice Address - Fax:414-962-6765
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI836-226103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical