Provider Demographics
NPI:1144438672
Name:DVORAK, SUSAN (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:DVORAK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 N 85TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4601
Mailing Address - Country:US
Mailing Address - Phone:414-259-8938
Mailing Address - Fax:
Practice Address - Street 1:9120 W HAMPTON AVE
Practice Address - Street 2:SUITE 90
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-4960
Practice Address - Country:US
Practice Address - Phone:414-466-9777
Practice Address - Fax:414-358-5590
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1423-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39094500Medicaid