Provider Demographics
NPI:1952465783
Name:COLLYARD, SUSAN BEVERLY (MA)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:BEVERLY
Last Name:COLLYARD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:B
Other - Last Name:BATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 18453
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-0453
Mailing Address - Country:US
Mailing Address - Phone:262-617-1258
Mailing Address - Fax:
Practice Address - Street 1:4929 W FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2324
Practice Address - Country:US
Practice Address - Phone:414-871-6122
Practice Address - Fax:414-871-2552
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100-226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor