Provider Demographics
NPI:1689640401
Name:MATZKE, SUSAN M (MS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:MATZKE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 N FOREST HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-8938
Mailing Address - Country:US
Mailing Address - Phone:608-752-4732
Mailing Address - Fax:608-757-2319
Practice Address - Street 1:1 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-3922
Practice Address - Country:US
Practice Address - Phone:608-757-0404
Practice Address - Fax:608-757-2319
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI463-125101YM0800X
WI3327-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39196700Medicaid