Provider Demographics
NPI:1285736249
Name:KOSNAR-TITTL, SUZETTE M (MA)
Entity type:Individual
Prefix:MS
First Name:SUZETTE
Middle Name:M
Last Name:KOSNAR-TITTL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:SUZETTE
Other - Middle Name:M
Other - Last Name:KOSNAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:529 S JEFFERSON ST STE 202
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4125
Mailing Address - Country:US
Mailing Address - Phone:920-884-2175
Mailing Address - Fax:920-884-6735
Practice Address - Street 1:529 S JEFFERSON ST STE 202
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4125
Practice Address - Country:US
Practice Address - Phone:920-884-2175
Practice Address - Fax:920-884-6735
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2376125101YP2500X
WI489124106H00000X
WI40441231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39722900Medicaid
WI000007055Medicare ID - Type Unspecified