Provider Demographics
NPI:1962530170
Name:SEUBERT, MARY L (LPC, CSAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:SEUBERT
Suffix:
Gender:F
Credentials:LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:COLOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54930-9406
Mailing Address - Country:US
Mailing Address - Phone:920-647-6679
Mailing Address - Fax:
Practice Address - Street 1:1519 3RD AVE
Practice Address - Street 2:
Practice Address - City:COLOMA
Practice Address - State:WI
Practice Address - Zip Code:54930-9406
Practice Address - Country:US
Practice Address - Phone:920-647-6679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1308101YA0400X
WI4555-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4555-125OtherSTATE LICENSE
WI1308-132OtherSTATE LICENSE