Healthcare Provider Details

I. General information

NPI: 1679016299
Provider Name (Legal Business Name): DION MICHELLE RACKS CAPSW, SAC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2016
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11414 W PARK PL
MILWAUKEE WI
53224-3500
US

IV. Provider business mailing address

11414 W PARK PL 202
MILWAUKEE WI
53224-3500
US

V. Phone/Fax

Practice location:
  • Phone: 414-397-8923
  • Fax:
Mailing address:
  • Phone: 414-397-8923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number128459
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17987
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number128459
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number128459
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number128459
License Number StateWI
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number128459
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: