Healthcare Provider Details

I. General information

NPI: 1760941116
Provider Name (Legal Business Name): QUINTON RICHARD WEDIG SAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2019
Last Update Date: 03/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2914 INDUSTRIAL DR
MADISON WI
53713-4047
US

IV. Provider business mailing address

328 ALPINE MEADOW CIR
OREGON WI
53575-3832
US

V. Phone/Fax

Practice location:
  • Phone: 608-223-3311
  • Fax: 608-204-8585
Mailing address:
  • Phone: 608-206-7804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16291
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number16291
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: