Healthcare Provider Details

I. General information

NPI: 1780262840
Provider Name (Legal Business Name): TRISTAN ALBERT ERTMAN SAC-IT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 03/31/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 STATE ROAD 67
KIEL WI
53042-1650
US

IV. Provider business mailing address

530 STATE ROAD 67
KIEL WI
53042-1650
US

V. Phone/Fax

Practice location:
  • Phone: 920-894-1374
  • Fax: 920-894-1373
Mailing address:
  • Phone: 920-894-1374
  • Fax: 920-894-1373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19029-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: