Provider Demographics
NPI:1013006329
Name:THOTTAKARA, GEORGE PAUL (MA CADC III)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:PAUL
Last Name:THOTTAKARA
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Gender:M
Credentials:MA CADC III
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Mailing Address - Street 1:2500 HALL AVE
Mailing Address - Street 2:SUITE A MARINETTE COUNTY HEALTH AND HUMAN SERVICES
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143
Mailing Address - Country:US
Mailing Address - Phone:715-732-7760
Mailing Address - Fax:715-732-7711
Practice Address - Street 1:1201 JACKSON ST
Practice Address - Street 2:MARINETTE COUNTY HEALTH AND HUMAN SERVICES
Practice Address - City:NIAGARA
Practice Address - State:WI
Practice Address - Zip Code:54151
Practice Address - Country:US
Practice Address - Phone:715-251-4555
Practice Address - Fax:715-251-1754
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
WI2579125101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2579125OtherLICENSE NUMBER
WI39187300Medicaid