Provider Demographics
NPI:1063613222
Name:FENRICH, SUSAN L (BC-HIS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:FENRICH
Suffix:
Gender:F
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2223 S MEMORIAL PL
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3715
Mailing Address - Country:US
Mailing Address - Phone:920-452-0213
Mailing Address - Fax:920-208-4301
Practice Address - Street 1:2223 S MEMORIAL PL
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3715
Practice Address - Country:US
Practice Address - Phone:920-452-0213
Practice Address - Fax:920-208-4301
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI612237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42822700Medicaid