Healthcare Provider Details

I. General information

NPI: 1477653533
Provider Name (Legal Business Name): DIANNA M SUSITTI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7330 W LAYTON AVE
MILWAUKEE WI
53220-3849
US

IV. Provider business mailing address

2717 N GRANDVIEW BLVD # 202
WAUKESHA WI
53188
US

V. Phone/Fax

Practice location:
  • Phone: 414-877-4570
  • Fax: 262-228-6257
Mailing address:
  • Phone: 262-513-0700
  • Fax: 262-513-0707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number349123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: