MEDICARE: LINDA M. TISO MSW, LCSW, SAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6969-123	WI
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	12605-131	WI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	001084974	OTHER	WI	MEDICARE, ELKHORN PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013937341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LINDA M. TISO MSW, LCSW, SAC

Provider Business Mailing Address
First Line	:	285 N JANACEK RD
Second Line	:
City	:	BROOKFIELD
State	:	WI
Zip	:	53045-6102
Country	:	US
Telephone Number	:	262-641-9050
Fax Number	:	262-641-9126

Provider Business Practice Location Address
First Line	:	3535 30TH AVE
Second Line	:	SUITE 202
City	:	KENOSHA
State	:	WI
Zip	:	53144-1632
Country	:	US
Telephone Number	:	262-842-0500
Fax Number	:	262-842-0502

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	05/26/2008

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