Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 15628-131 | WI |
NPI | 1003196494 |
---|---|
Provider Name | Desiree Ciokiewicz |
First Address | Chippewa Falls, WI 54729-5407 |
Second Address | Chippewa Falls, WI 54729-5407 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2011 |
Last Update Date | 17/08/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
15628-131 | STATE (01) | WI |