Provider Demographics
NPI:1497009765
Name:DE SHAZER, SUSAN KATHERINE ANNE (LMT)
Entity Type:Individual
Prefix:
First Name:SUSAN KATHERINE
Middle Name:ANNE
Last Name:DE SHAZER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6789 N GREEN BAY AVE
Mailing Address - Street 2:4U
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-3472
Mailing Address - Country:US
Mailing Address - Phone:414-292-3900
Mailing Address - Fax:414-292-3901
Practice Address - Street 1:6789 N GREEN BAY AVE
Practice Address - Street 2:4U
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-3472
Practice Address - Country:US
Practice Address - Phone:414-292-3900
Practice Address - Fax:414-292-3901
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11297-146174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist