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General NPI Number Information
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NPI Number | 1447574702
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Entity Type | Individual
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Provider Name | THERESA A ELLISON CSAC
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Gender | Female
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Dates
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Enumeration Date | 03/16/2010
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Last Update Date | 03/16/2010
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Provider Practice Location Address
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Address Line | 13 BAY ST
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City | CHIPPEWA FALLS
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State | WI
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Zip | 54729-2437
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Country | US
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Telephone | 715-726-9023
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Fax | 715-726-9055
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Provider Business Mailing Address
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Address Line | 17230 95TH AVE
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City | CHIPPEWA FALLS
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State | WI
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Zip | 54729-5189
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Country | US
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Telephone | 715-896-3555
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 13165
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License Number State | WI
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