Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 15413-131 | WI |
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 302375 | MN |
NPI | 1003079708 |
---|---|
Provider Name | Mr. Charles D Lipford |
First Address | Mauston, WI 53948-2101 |
Second Address | Mauston, WI 53948-2101 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2008 |
Last Update Date | 30/06/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003079708 | (05) | WI |