Provider Demographics
NPI:1659634178
Name:WHITEHEAD, SUSAN LEE (LPC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LEE
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W337S9679 RED BRAE DR
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-8626
Mailing Address - Country:US
Mailing Address - Phone:262-501-1814
Mailing Address - Fax:
Practice Address - Street 1:101 W BROADWAY
Practice Address - Street 2:2ND FL
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4833
Practice Address - Country:US
Practice Address - Phone:262-547-5567
Practice Address - Fax:262-547-1608
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4829-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional