Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 1172 | WI |
NPI | 1003976473 |
---|---|
Provider Name | Darlene Leary |
First Address | Appleton, WI 54912-8003 |
Second Address | Menasha, WI 54952-1115 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/12/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
39325700 | (05) | WI |