Healthcare Provider Details

I. General information

NPI: 1285641647
Provider Name (Legal Business Name): MR. JOHN NICHOLAS WIRKUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOHN WIRKUS CADC3

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16535 W BLUEMOUND RD
BROOKFIELD WI
53005-5936
US

IV. Provider business mailing address

111 WEST ST
JOHNSON CREEK WI
53038-9503
US

V. Phone/Fax

Practice location:
  • Phone: 262-542-3255
  • Fax: 262-821-6180
Mailing address:
  • Phone: 920-699-3703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1006
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: