Healthcare Provider Details

I. General information

NPI: 1629244298
Provider Name (Legal Business Name): LADD E. WHITE CSAC AND LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 SOUTH ST APT 5
JOHNSON CREEK WI
53038-9519
US

IV. Provider business mailing address

305 SOUTH ST APT 5
JOHNSON CREEK WI
53038-9519
US

V. Phone/Fax

Practice location:
  • Phone: 920-988-7160
  • Fax: 414-540-2171
Mailing address:
  • Phone: 920-988-7160
  • Fax: 414-540-2171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4097-125
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1946-132
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: