Provider Demographics
NPI:1720132053
Name:SEBASTIAN, SUSAN M (LPC, CSAC INDCS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:SEBASTIAN
Suffix:
Gender:F
Credentials:LPC, CSAC INDCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 W MAIN ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-1995
Mailing Address - Country:US
Mailing Address - Phone:608-446-0888
Mailing Address - Fax:866-289-2601
Practice Address - Street 1:162 W MAIN ST
Practice Address - Street 2:SUITE G
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-1995
Practice Address - Country:US
Practice Address - Phone:608-446-0888
Practice Address - Fax:866-289-2601
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3734-125101YP2500X
WI2050-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39394800Medicaid