MEDICARE: MS. ERIN M LECKWEE SAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	15864-131	WI

General Provider Information

NPI Number	:	1568883999
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ERIN M LECKWEE SAC

Provider Business Mailing Address
First Line	:	5109 WORLD DAIRY DR
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53718-3807
Country	:	US
Telephone Number	:	608-242-0220
Fax Number	:	608-242-1166

Provider Business Practice Location Address
First Line	:	5109 WORLD DAIRY DR
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53718-3807
Country	:	US
Telephone Number	:	608-242-0220
Fax Number	:	608-242-1166

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2014
Last Update Date	:	02/11/2014

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