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NPI Code Detail

MEDICARE: MISS SUSAN BEVERLY COLLYARD MA

MEDICARE: MISS SUSAN BEVERLY COLLYARD MA
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
1101Y00000XCounselor100-226WI

General Provider Information

NPI Number : 1952465783
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISS SUSAN BEVERLY COLLYARD MA
Provider Business Mailing Address
First Line : PO BOX 18453
Second Line :
City : MILWAUKEE
State : WI
Zip : 53218-0453
Country : US
Telephone Number : 262-617-1258
Fax Number :
Provider Business Practice Location Address
First Line : 4929 W FOND DU LAC AVE
Second Line :
City : MILWAUKEE
State : WI
Zip : 53216-2324
Country : US
Telephone Number : 414-871-6122
Fax Number : 414-871-2552
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/19/2006
Last Update Date : 12/17/2013

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Directions to “ MISS SUSAN BEVERLY COLLYARD MA” Practice Location

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