Healthcare Provider Details

I. General information

NPI: 1518358506
Provider Name (Legal Business Name): TONI LIDDY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E LOCUST ST
MILWAUKEE WI
53212-2634
US

IV. Provider business mailing address

2369 S 57TH ST
WEST ALLIS WI
53219-2215
US

V. Phone/Fax

Practice location:
  • Phone: 414-429-6522
  • Fax: 414-502-0192
Mailing address:
  • Phone: 414-429-6522
  • Fax: 414-502-0192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number244-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number244-125
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number244-125
License Number StateWI

VIII. Authorized Official

Name: ANTONETTE MARIE LIDDY
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: M.S. LPC NCC
Phone: 414-429-6522