Healthcare Provider Details

I. General information

NPI: 1679906952
Provider Name (Legal Business Name): MARINA READ CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARINA SMITH CSAC

II. Dates (important events)

Enumeration Date: 08/09/2013
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1126 S 70TH ST 113-3
MILWAUKEE WI
53214-3151
US

IV. Provider business mailing address

721 AMERICAN AVE SUITE 501
WAUKESHA WI
53188-5071
US

V. Phone/Fax

Practice location:
  • Phone: 414-475-2788
  • Fax: 414-476-8695
Mailing address:
  • Phone: 262-928-4036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16033-132
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2092
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: