Provider Demographics
NPI:1922748532
Name:WEBER, SUSAN KAYE
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:KAYE
Last Name:WEBER
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:SUSAN
Other - Middle Name:KAYE
Other - Last Name:WQAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA, LAC
Mailing Address - Street 1:115 E HAVENS AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-4462
Mailing Address - Country:US
Mailing Address - Phone:605-301-8720
Mailing Address - Fax:605-942-7300
Practice Address - Street 1:115 E HAVENS AVE STE 106
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-4462
Practice Address - Country:US
Practice Address - Phone:605-301-8720
Practice Address - Fax:605-942-7300
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD01051150101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)