Provider Demographics
NPI:1750403101
Name:PANGER, SUSAN MARIE (LMFT LCSW)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:PANGER
Suffix:
Gender:F
Credentials:LMFT LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53141-0096
Mailing Address - Country:US
Mailing Address - Phone:262-652-9599
Mailing Address - Fax:262-652-0009
Practice Address - Street 1:811 60TH ST
Practice Address - Street 2:2E
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-4074
Practice Address - Country:US
Practice Address - Phone:262-652-9599
Practice Address - Fax:262-652-0009
Is Sole Proprietor?:No
Enumeration Date:2007-04-05
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2606-1231041C0700X
WI558-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical