Provider Demographics
NPI:1013278548
Name:SUSSEK, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:SUSSEK
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 1:169 STARK ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:WI
Mailing Address - Zip Code:53956-1298
Mailing Address - Country:US
Mailing Address - Phone:608-423-6636
Mailing Address - Fax:
Practice Address - Street 1:169 STARK ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:WI
Practice Address - Zip Code:53956-1298
Practice Address - Country:US
Practice Address - Phone:608-423-6636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9059-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical