1093930455 NPI number — ANGELA M PEDRETTI MA LPC

Table of content: ANGELA M PEDRETTI MA LPC (NPI 1093930455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093930455 NPI number — ANGELA M PEDRETTI MA LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEDRETTI
Provider First Name:
ANGELA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093930455
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1998 LONG LAKE LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COMSTOCK
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-822-8614
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2661 COUNTY HIGHWAY I
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHIPPEWA FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54729-5407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-723-1811
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LPC 1098 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 3854 125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 43714500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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