Provider Demographics
NPI:1609972280
Name:DIEDERICH, SUZETTE CAROLYN-EVE (MS ED, LPC)
Entity Type:Individual
Prefix:MRS
First Name:SUZETTE
Middle Name:CAROLYN-EVE
Last Name:DIEDERICH
Suffix:
Gender:F
Credentials:MS ED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3645 WILDCAT TRL APT 3
Mailing Address - Street 2:
Mailing Address - City:NEW FRANKEN
Mailing Address - State:WI
Mailing Address - Zip Code:54229-9207
Mailing Address - Country:US
Mailing Address - Phone:920-366-8590
Mailing Address - Fax:
Practice Address - Street 1:123 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2831
Practice Address - Country:US
Practice Address - Phone:920-770-4088
Practice Address - Fax:651-705-0026
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3387-125101YM0800X, 101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40967700Medicaid
WI60291900 ID=7OtherEDI TRADING PARTNER NO.
WI3387-125OtherLICENSED PROFESSIONAL COU