Provider Demographics
NPI:1467662890
Name:KETTLER, SUSAN L (MSSW, LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:KETTLER
Suffix:
Gender:F
Credentials:MSSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10475 STATE ROAD 27
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-2000
Mailing Address - Country:US
Mailing Address - Phone:715-934-3677
Mailing Address - Fax:715-934-3676
Practice Address - Street 1:10475 STATE ROAD 27
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-2000
Practice Address - Country:US
Practice Address - Phone:715-934-3677
Practice Address - Fax:715-934-3676
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13070101YA0400X
WI7159-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40992100Medicaid