MEDICARE: SUSAN M SEBASTIAN LPC, CSAC. INDCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	3734-125	WI
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	2050-132	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720132053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN M SEBASTIAN LPC, CSAC. INDCS

Provider Business Mailing Address
First Line	:	162 W MAIN ST
Second Line	:	SUITE G
City	:	WHITEWATER
State	:	WI
Zip	:	53190-1995
Country	:	US
Telephone Number	:	608-446-0888
Fax Number	:	866-289-2601

Provider Business Practice Location Address
First Line	:	162 W MAIN ST
Second Line	:	SUITE G
City	:	WHITEWATER
State	:	WI
Zip	:	53190-1995
Country	:	US
Telephone Number	:	608-446-0888
Fax Number	:	866-289-2601

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	12/09/2008

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