Provider Demographics
NPI:1255405759
Name:KLINGER WALLOCH, SUSAN (MSSW LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KLINGER WALLOCH
Suffix:
Gender:F
Credentials:MSSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 N BRIDGE STREET
Mailing Address - Street 2:RM 122
Mailing Address - City:CHIPPEW FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-1876
Mailing Address - Country:US
Mailing Address - Phone:715-726-7788
Mailing Address - Fax:715-726-4560
Practice Address - Street 1:711 N BRIDGE STREET
Practice Address - Street 2:RM 122
Practice Address - City:CHIPPEW FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-1876
Practice Address - Country:US
Practice Address - Phone:715-726-7788
Practice Address - Fax:715-726-4560
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI422 1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI17950OtherSECURITY HEALTH
WI39576300Medicaid