Provider Demographics
NPI:1316907694
Name:ADESSO, VINCENT JOSEPH (PHD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:JOSEPH
Last Name:ADESSO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5555 NORTH PORT WASHINGTON RD
Mailing Address - Street 2:STE 304
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4927
Mailing Address - Country:US
Mailing Address - Phone:414-967-9552
Mailing Address - Fax:414-967-9550
Practice Address - Street 1:5555 NORTH PORT WASHINGTON RD
Practice Address - Street 2:STE 304
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-4927
Practice Address - Country:US
Practice Address - Phone:414-967-9552
Practice Address - Fax:414-967-9550
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI608057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000084219Medicaid
WI000084219Medicare ID - Type Unspecified