Basic Information
| Provider Information | |||||||||
| NPI: | 1487219838 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | INDERBITZEN | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15735 W US HIGHWAY 63 | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548436475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156342541 | ||||||||
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| Practice Location | |||||||||
| Address1: | 105 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | RICE LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548681362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157365437 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2019 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 131408-121 | WI | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 9894 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 131408 | WI | N | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 100087784 | 05 | WI | MEDICAID |