Provider Demographics
NPI:1881737708
Name:ROE, SUZANNE HELENE (11282132-CSAC)
Entity type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:HELENE
Last Name:ROE
Suffix:
Gender:F
Credentials:11282132-CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 RIVERSIDE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-3433
Mailing Address - Country:US
Mailing Address - Phone:262-496-1562
Mailing Address - Fax:
Practice Address - Street 1:1517 E HUEBBE PKWY
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1795
Practice Address - Country:US
Practice Address - Phone:608-313-0524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11282132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39395800Medicaid