Provider Demographics
NPI:1356441018
Name:MICKEL, SUSAN F (MD, PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:F
Last Name:MICKEL
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-2405
Mailing Address - Country:US
Mailing Address - Phone:262-638-6744
Mailing Address - Fax:262-638-6540
Practice Address - Street 1:1717 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-2405
Practice Address - Country:US
Practice Address - Phone:262-638-6744
Practice Address - Fax:262-638-6540
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI287352084N0400X
WI3113-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1356441018Medicaid
WI1356441018Medicaid
B55084Medicare UPIN
WI322500129Medicare PIN