Provider Demographics
NPI:1033247606
Name:SALLIS, ANTONIA (MS,SAC,DPI TEACHER)
Entity Type:Individual
Prefix:
First Name:ANTONIA
Middle Name:
Last Name:SALLIS
Suffix:
Gender:F
Credentials:MS,SAC,DPI TEACHER
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 16725
Mailing Address - Street 2:3762 NORTH 38TH STREET
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-0725
Mailing Address - Country:US
Mailing Address - Phone:414-364-0406
Mailing Address - Fax:414-442-6387
Practice Address - Street 1:6040 W LISBON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2116
Practice Address - Country:US
Practice Address - Phone:414-364-0406
Practice Address - Fax:414-442-6387
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15375-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI15375-130OtherSUBSTANCE ABUSE COUNSELOR