Provider Demographics
NPI:1992878441
Name:CHRISTIANSEN, REGINALD C (CADCIII LADC)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:C
Last Name:CHRISTIANSEN
Suffix:
Gender:M
Credentials:CADCIII LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:54011-0670
Mailing Address - Country:US
Mailing Address - Phone:715-273-6770
Mailing Address - Fax:715-273-6862
Practice Address - Street 1:412 W KINNE ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:WI
Practice Address - Zip Code:54011
Practice Address - Country:US
Practice Address - Phone:715-273-6770
Practice Address - Fax:715-273-6770
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI812101YA0400X
MN301067101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39345400Medicaid
MN5H765CHOtherBLUECROSS BLUESHIELD
MN920461021641OtherPREFERRED ONE