Provider Demographics
NPI:1417955774
Name:PREUSS, PAULINE ANN (MA)
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:ANN
Last Name:PREUSS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:PAULINE
Other - Middle Name:ANN
Other - Last Name:VANDERGRINTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:290 17TH ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-6066
Mailing Address - Country:US
Mailing Address - Phone:920-924-9359
Mailing Address - Fax:920-924-9359
Practice Address - Street 1:6944 W FOREST HOME AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-2917
Practice Address - Country:US
Practice Address - Phone:262-719-3825
Practice Address - Fax:414-321-8588
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3467-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional