Healthcare Provider Details

I. General information

NPI: 1790465300
Provider Name (Legal Business Name): NATHAN J ZICCARELLI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S 6TH ST
MILWAUKEE WI
53204-2301
US

IV. Provider business mailing address

1111 S 6TH ST
MILWAUKEE WI
53204-2301
US

V. Phone/Fax

Practice location:
  • Phone: 414-643-8530
  • Fax: 414-647-8602
Mailing address:
  • Phone: 414-643-8530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20195-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: