Healthcare Provider Details

I. General information

NPI: 1821368754
Provider Name (Legal Business Name): ASHLEY B. WITLACIL SAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 11/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 MIDWAY RD
MENASHA WI
54952-1115
US

IV. Provider business mailing address

1095 MIDWAY RD
MENASHA WI
54952-1115
US

V. Phone/Fax

Practice location:
  • Phone: 920-720-2300
  • Fax: 920-720-3719
Mailing address:
  • Phone: 920-720-2300
  • Fax: 920-720-3806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15855
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5755
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: