Provider Demographics
NPI:1366998403
Name:BARREN, ELISHA A SR (SAC-IT)
Entity type:Individual
Prefix:MR
First Name:ELISHA
Middle Name:A
Last Name:BARREN
Suffix:SR
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 W HIGHLAND BLVD
Mailing Address - Street 2:APT 212
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-4331
Mailing Address - Country:US
Mailing Address - Phone:414-839-0088
Mailing Address - Fax:
Practice Address - Street 1:2555 N MLK DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2709
Practice Address - Country:US
Practice Address - Phone:414-372-8080
Practice Address - Fax:414-267-8570
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-29
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16713-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1366998403Medicaid