Healthcare Provider Details

I. General information

NPI: 1013937341
Provider Name (Legal Business Name): LINDA M. TISO MSW, LCSW, SAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 05/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 30TH AVE SUITE 202
KENOSHA WI
53144-1632
US

IV. Provider business mailing address

285 N JANACEK RD
BROOKFIELD WI
53045-6102
US

V. Phone/Fax

Practice location:
  • Phone: 262-842-0500
  • Fax: 262-842-0502
Mailing address:
  • Phone: 262-641-9050
  • Fax: 262-641-9126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6969-123
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12605-131
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: