Provider Demographics
NPI:1689992224
Name:KUSSARD, STACIE M
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:M
Last Name:KUSSARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 N GRANDVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-6105
Mailing Address - Country:US
Mailing Address - Phone:262-549-6600
Mailing Address - Fax:262-549-6698
Practice Address - Street 1:2842 S BUSINESS DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-6518
Practice Address - Country:US
Practice Address - Phone:920-458-6527
Practice Address - Fax:920-458-6623
Is Sole Proprietor?:No
Enumeration Date:2010-05-06
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5761-125101YM0800X
WI15810-132101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health