Provider Demographics
NPI:1437766383
Name:HUMPHREY, SUSAN MERCY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MERCY
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 ALYSSA ST
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-8197
Mailing Address - Country:US
Mailing Address - Phone:254-220-5528
Mailing Address - Fax:
Practice Address - Street 1:500 E VETERANS ST
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-3105
Practice Address - Country:US
Practice Address - Phone:254-220-5528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9503-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical