Healthcare Provider Details

I. General information

NPI: 1912147828
Provider Name (Legal Business Name): EVANGELINE M SUQUET MAC, CSAC, LPC, CSIT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2009
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W9850 AIRPORT ROAD
BLACK RIVER FALLS WI
54615
US

IV. Provider business mailing address

PO BOX 918 W9850 AIRPORT ROAD
BLACK RIVER FALLS WI
54615
US

V. Phone/Fax

Practice location:
  • Phone: 715-284-9851
  • Fax: 715-284-3434
Mailing address:
  • Phone: 715-284-9851
  • Fax: 715-284-3434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15705-132
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5231-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: