Provider Demographics
NPI:1477653533
Name:SUSITTI, DIANNA M (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:M
Last Name:SUSITTI
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 1:2717 N GRANDVIEW BLVD
Mailing Address - Street 2:# 202
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188
Mailing Address - Country:US
Mailing Address - Phone:262-513-0700
Mailing Address - Fax:262-513-0707
Practice Address - Street 1:7330 W LAYTON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53220-3849
Practice Address - Country:US
Practice Address - Phone:414-877-4570
Practice Address - Fax:262-228-6257
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI349123104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21300600Medicaid