Healthcare Provider Details

I. General information

NPI: 1659293868
Provider Name (Legal Business Name): LEWIS RICE SAC-IT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 CHESTNUT ST
WEST BEND WI
53095-3014
US

IV. Provider business mailing address

N4770 SAINT JOHNS RD
RUBICON WI
53078-9761
US

V. Phone/Fax

Practice location:
  • Phone: 262-306-9800
  • Fax:
Mailing address:
  • Phone: 262-665-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number21094130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: