Provider Demographics
NPI:1487219838
Name:INDERBITZEN, SEAN M (LCSW)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:M
Last Name:INDERBITZEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15735 W US HIGHWAY 63
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-6475
Mailing Address - Country:US
Mailing Address - Phone:715-634-2541
Mailing Address - Fax:
Practice Address - Street 1:105 WEST AVE
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-1362
Practice Address - Country:US
Practice Address - Phone:715-736-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI131408-121104100000X
WI98941041C0700X
WI131408104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100087784Medicaid