1588007165 NPI number — SUSAN ANNE GEORGE LPC

Table of content: SUSAN ANNE GEORGE LPC (NPI 1588007165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588007165 NPI number — SUSAN ANNE GEORGE LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GEORGE
Provider First Name:
SUSAN
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FOWLER
Provider Other First Name:
SUSAN
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1588007165
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W4460 MARY HILL PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOND DU LAC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54937-9313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-929-0184
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
439 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOND DU LAC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54935-4951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-251-7005
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/12/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  3883-125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)