Provider Demographics
NPI:1811256332
Name:IGNAZITO-WILHELM, SUSAN (MAC, LPC)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:IGNAZITO-WILHELM
Suffix:
Gender:F
Credentials:MAC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7218 TALL OAK CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-5650
Mailing Address - Country:US
Mailing Address - Phone:314-375-6475
Mailing Address - Fax:
Practice Address - Street 1:3134 SUTTON BLVD
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MO
Practice Address - Zip Code:63143-3910
Practice Address - Country:US
Practice Address - Phone:314-375-6475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011039644101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499508802Medicaid