Healthcare Provider Details

I. General information

NPI: 1619618071
Provider Name (Legal Business Name): LAURA MAE PASKE SAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 MIDWAY RD
MENASHA WI
54952-1115
US

IV. Provider business mailing address

731 S TELULAH AVE
APPLETON WI
54915-3422
US

V. Phone/Fax

Practice location:
  • Phone: 920-720-2300
  • Fax: 920-720-3719
Mailing address:
  • Phone: 920-889-3239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16555
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: