Provider Demographics
NPI:1720522550
Name:FAHRENHOLZ, ANNEY RENEE (MS, BCBA)
Entity type:Individual
Prefix:
First Name:ANNEY
Middle Name:RENEE
Last Name:FAHRENHOLZ
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 LE CHATEAU DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5056
Mailing Address - Country:US
Mailing Address - Phone:402-871-7545
Mailing Address - Fax:
Practice Address - Street 1:510 E WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-4865
Practice Address - Country:US
Practice Address - Phone:920-257-4601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI154-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100009466Medicaid