Healthcare Provider Details

I. General information

NPI: 1346271541
Provider Name (Legal Business Name): MICHAEL L FERNETTE CADC III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

200 W ALONA LN
LANCASTER WI
53813-2202
US

IV. Provider business mailing address

200 W ALONA LN
LANCASTER WI
53813-2202
US

V. Phone/Fax

Practice location:
  • Phone: 608-723-6357
  • Fax: 608-723-4417
Mailing address:
  • Phone: 608-723-6357
  • Fax: 608-723-4417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1839
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: