Healthcare Provider Details

I. General information

NPI: 1023669926
Provider Name (Legal Business Name): SUSAN MARIE CONDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2019
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18000 W SARAH LN
BROOKFIELD WI
53045-5853
US

IV. Provider business mailing address

12970 W BLUEMOUND RD STE 200
ELM GROVE WI
53122-2607
US

V. Phone/Fax

Practice location:
  • Phone: 262-267-8560
  • Fax:
Mailing address:
  • Phone: 262-780-1020
  • Fax: 262-780-1022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number261QM0801X
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: