Provider Demographics
NPI:1588007165
Name:GEORGE, SUSAN ANNE (LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANNE
Last Name:GEORGE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ANNE
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W4460 MARY HILL PARK DR
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54937-9313
Mailing Address - Country:US
Mailing Address - Phone:920-929-0184
Mailing Address - Fax:
Practice Address - Street 1:439 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4951
Practice Address - Country:US
Practice Address - Phone:920-251-7005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3883-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional