Provider Demographics
NPI:1558171017
Name:VENKATARAMAN, PRABHU (LPC-IT)
Entity type:Individual
Prefix:
First Name:PRABHU
Middle Name:
Last Name:VENKATARAMAN
Suffix:
Gender:M
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-5211
Mailing Address - Country:US
Mailing Address - Phone:309-573-5154
Mailing Address - Fax:
Practice Address - Street 1:1807 N CENTER ST STE 204
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-1005
Practice Address - Country:US
Practice Address - Phone:920-887-8751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8241-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty