Healthcare Provider Details

I. General information

NPI: 1063613222
Provider Name (Legal Business Name): SUSAN L FENRICH BC-HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2223 S MEMORIAL PL
SHEBOYGAN WI
53081-3715
US

IV. Provider business mailing address

2223 S MEMORIAL PL
SHEBOYGAN WI
53081-3715
US

V. Phone/Fax

Practice location:
  • Phone: 920-452-0213
  • Fax: 920-208-4301
Mailing address:
  • Phone: 920-452-0213
  • Fax: 920-208-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number612
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: