Healthcare Provider Details

I. General information

NPI: 1497883888
Provider Name (Legal Business Name): PATRICIA A USTIANOWSKI CADCIII
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PATRICIA A LARSON CADCIII

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 PEACE PIPE ROAD
LAC DU FLAMBEAU WI
54538-0189
US

IV. Provider business mailing address

P.O. BOX 189 533 PEACE PIPE ROAD
LAC DU FLAMBEAU WI
54538-0189
US

V. Phone/Fax

Practice location:
  • Phone: 715-588-1511
  • Fax: 715-588-3903
Mailing address:
  • Phone: 715-588-1511
  • Fax: 715-588-3903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1765
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number13667
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: