1700279619 NPI number — RHEA L VACHA LCSW

Table of content: RHEA L VACHA LCSW (NPI 1700279619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700279619 NPI number — RHEA L VACHA LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VACHA
Provider First Name:
RHEA
Provider Middle Name:
L
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:
ELLESTAD
Provider Other First Name:
RHEA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CAPSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700279619
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
742 CRESTHAVEN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COTTAGE GROVE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53527-9677
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-513-9637
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 W MIFFLIN ST STE 502
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53703-2589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-513-9637
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2015

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:  9393-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 129639-121 , 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: 1700279619 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".