Provider Demographics
NPI:1881777308
Name:WHEELER, SUSAN ADELE (LPCMH CCDC3)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ADELE
Last Name:WHEELER
Suffix:
Gender:F
Credentials:LPCMH CCDC3
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ADELE
Other - Last Name:KVIKSTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2920 SHERIDAN LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-5350
Mailing Address - Country:US
Mailing Address - Phone:605-348-0477
Mailing Address - Fax:605-348-0479
Practice Address - Street 1:2920 SHERIDAN LAKE ROAD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-5350
Practice Address - Country:US
Practice Address - Phone:605-348-0477
Practice Address - Fax:605-348-0479
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCCDC3950962101Y00000X
SDLPCMH2072101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6575440Medicaid