Healthcare Provider Details

I. General information

NPI: 1316213929
Provider Name (Legal Business Name): ANDREW DEVERA RONQUILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6980 N PORT WASHINGTON RD
MILWAUKEE WI
53217-3900
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 414-351-7100
  • Fax: 414-247-4082
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16286-130
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5489
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: