MEDICARE: MONIQUE MCKNUCKLE SAC-IT

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	21077-130	WI

General Provider Information

NPI Number	:	1720933088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONIQUE MCKNUCKLE SAC-IT

Provider Business Mailing Address
First Line	:	210 E OLIN AVE
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53713-1434
Country	:	US
Telephone Number	:	608-807-1428
Fax Number	:	608-807-1429

Provider Business Practice Location Address
First Line	:	210 E OLIN AVE
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53713-1434
Country	:	US
Telephone Number	:	608-807-1428
Fax Number	:	608-807-1429

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

Provider Enumeration Date	:	03/02/2026
Last Update Date	:	03/02/2026

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