Provider Demographics
NPI:1952415085
Name:BRUST, SUSAN R (PSYCH NP, CNS)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:R
Last Name:BRUST
Suffix:
Gender:F
Credentials:PSYCH NP, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N1736 20TH RD
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-5920
Mailing Address - Country:US
Mailing Address - Phone:507-269-1841
Mailing Address - Fax:
Practice Address - Street 1:1100 LAKE VIEW DR
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-6799
Practice Address - Country:US
Practice Address - Phone:715-848-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8103363LF0000X
MNR1306952363LP0808X
WI8103-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN125674OtherMMSI
MN162P6BROtherBCBS IND NUMBER
MN1351033600Medicaid
MN164P4SUOtherBCBS GROUP NUMBER
MN83-60115OtherUBH
MNP25142Medicare UPIN
MN1351033600Medicaid