Provider Demographics
NPI:1568872067
Name:SUCKOW, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:SUCKOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 WEST GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209
Mailing Address - Country:US
Mailing Address - Phone:262-641-8269
Mailing Address - Fax:
Practice Address - Street 1:16985 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5946
Practice Address - Country:US
Practice Address - Phone:262-641-8269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI924-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist