Healthcare Provider Details

I. General information

NPI: 1497446363
Provider Name (Legal Business Name): ANTHONY PAUSTIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 E LONGVIEW DR STE C
APPLETON WI
54911-2149
US

IV. Provider business mailing address

997 BAYVIEW RD
NEENAH WI
54956-4959
US

V. Phone/Fax

Practice location:
  • Phone: 920-238-3340
  • Fax:
Mailing address:
  • Phone: 920-419-2171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: