Healthcare Provider Details

I. General information

NPI: 1760747448
Provider Name (Legal Business Name): LISA R ZILLMER BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 SAINT ANDREW ST STE 100
LA CROSSE WI
54603-3301
US

IV. Provider business mailing address

W11404 SPRING CREEK RD #31
BLACK RIVER FALLS WI
54615-5980
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-6266
  • Fax:
Mailing address:
  • Phone: 715-284-5697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number11111-120
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: