1164718151 NPI number — ANGELA DELLISE LPC, CSAC, CS-IT

Table of content: ANGELA DELLISE LPC, CSAC, CS-IT (NPI 1164718151)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164718151 NPI number — ANGELA DELLISE LPC, CSAC, CS-IT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DELLISE
Provider First Name:
ANGELA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, CSAC, CS-IT
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:
1164718151
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3900 W BROWN DEER RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
BROWN DEER
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53209-1220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-540-2170
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6233 DURAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT PLEASANT
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53406-4961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-554-8165
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/28/2011

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:  5385-125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YA0400X , with the licence number: 16057-130 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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