Provider Demographics
NPI:1487549960
Name:DIERCKS, SUSAN D
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:DIERCKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18909 MANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-5209
Mailing Address - Country:US
Mailing Address - Phone:563-568-9848
Mailing Address - Fax:
Practice Address - Street 1:13056 ATWOOD AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-3721
Practice Address - Country:US
Practice Address - Phone:402-916-9421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-12
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE14427101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health