Provider Demographics
NPI:1104111236
Name:ANTHONY, THERESA (SAC-IT, CS-IT)
Entity type:Individual
Prefix:MISS
First Name:THERESA
Middle Name:
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:SAC-IT, CS-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6815 W CAPITOL DR STE 301
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2056
Mailing Address - Country:US
Mailing Address - Phone:414-215-8477
Mailing Address - Fax:
Practice Address - Street 1:6815 W CAPITOL DR STE 301
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2056
Practice Address - Country:US
Practice Address - Phone:414-215-8477
Practice Address - Fax:414-616-9747
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15010133101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)