Healthcare Provider Details

I. General information

NPI: 1811246986
Provider Name (Legal Business Name): SUSAN LEIGH HEGEDUS CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2012
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 N PROSPECT AVE
MILWAUKEE WI
53202-1933
US

IV. Provider business mailing address

1891 SUMAC CT UNIT B
GRAFTON WI
53024-2954
US

V. Phone/Fax

Practice location:
  • Phone: 414-298-8600
  • Fax:
Mailing address:
  • Phone: 414-659-6332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7334-120
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: