1205830965 NPI number — ROBERTA A BRONECKI LCSW

Table of content: ROBERTA A BRONECKI LCSW (NPI 1205830965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205830965 NPI number — ROBERTA A BRONECKI LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRONECKI
Provider First Name:
ROBERTA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TESAR
Provider Other First Name:
ROBERTA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205830965
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 359
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAUSTON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53948-0359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-847-7575
Provider Business Mailing Address Fax Number:
608-847-3096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 GRAYSIDE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAUSTON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53948-1913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-847-7575
Provider Business Practice Location Address Fax Number:
608-847-3096
Provider Enumeration Date:
06/10/2005

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: 1041C0700X , with the licence number:  7163 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 7163-123 , 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: 11988111 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 40983800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013375104 . This is a "AGENCY NPI NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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