Healthcare Provider Details

I. General information

NPI: 1811562739
Provider Name (Legal Business Name): ANTHONY JAMES UTRIE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6622 OFFSHORE DR
MADISON WI
53705-4236
US

IV. Provider business mailing address

6622 OFFSHORE DR
MADISON WI
53705-4236
US

V. Phone/Fax

Practice location:
  • Phone: 608-571-2536
  • Fax: 920-887-8839
Mailing address:
  • Phone: 920-296-6599
  • Fax: 920-887-8839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19383-130
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11279-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: