Provider Demographics
NPI:1497757090
Name:LILJEGREN, SUSAN MARIE (MSSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:LILJEGREN
Suffix:
Gender:F
Credentials:MSSW, LCSW
Other - Prefix:MS
Other - First Name:ZANN
Other - Middle Name:
Other - Last Name:LILJEGREN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSSW, LCSW
Mailing Address - Street 1:424 YELLOWSTONE AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-9309
Mailing Address - Country:US
Mailing Address - Phone:307-578-2919
Mailing Address - Fax:307-578-2920
Practice Address - Street 1:424 YELLOWSTONE AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-9309
Practice Address - Country:US
Practice Address - Phone:307-578-2919
Practice Address - Fax:307-578-2920
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35-1231041C0700X
WY6141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0001Medicare ID - Type Unspecified