Provider Demographics
NPI:1104534288
Name:NOVACK, CONNOR JOHN (LCSW)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:JOHN
Last Name:NOVACK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 N HOLTON ST STE 400
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1064
Mailing Address - Country:US
Mailing Address - Phone:262-305-0948
Mailing Address - Fax:
Practice Address - Street 1:4200 N HOLTON ST STE 400
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1064
Practice Address - Country:US
Practice Address - Phone:262-305-0948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10066-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical