Provider Demographics
NPI:1710042262
Name:GINGRICH, SUZANNE (MSW LCSW)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:GINGRICH
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-2571
Mailing Address - Country:US
Mailing Address - Phone:262-338-2717
Mailing Address - Fax:262-338-9767
Practice Address - Street 1:111 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-2571
Practice Address - Country:US
Practice Address - Phone:262-338-2717
Practice Address - Fax:262-338-9767
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3261-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39253700Medicaid
WI84285005Medicare ID - Type Unspecified