Provider Demographics
NPI:1104046168
Name:ENDES, SUSAN C (MS ATRL BC)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:C
Last Name:ENDES
Suffix:
Gender:F
Credentials:MS ATRL BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 N 99 ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4310
Mailing Address - Country:US
Mailing Address - Phone:414-258-6099
Mailing Address - Fax:
Practice Address - Street 1:2020 W WELLS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233
Practice Address - Country:US
Practice Address - Phone:414-937-2096
Practice Address - Fax:414-937-2021
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69036103TP2701X, 221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Not Answered221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41001000Medicaid