Provider Demographics
NPI:1669686531
Name:SUSZEK, HOLLY ANN (MS,CCC,SLP)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:ANN
Last Name:SUSZEK
Suffix:
Gender:F
Credentials:MS,CCC,SLP
Other - Prefix:MISS
Other - First Name:HOLLY
Other - Middle Name:ANN
Other - Last Name:RUSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,CCC,SLP
Mailing Address - Street 1:3904 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-2357
Mailing Address - Country:US
Mailing Address - Phone:608-215-8204
Mailing Address - Fax:
Practice Address - Street 1:960 S RAPIDS RD
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-4146
Practice Address - Country:US
Practice Address - Phone:920-684-1144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2858154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42581400Medicaid