Provider Demographics
NPI:1043675127
Name:BEHNKE, ANDREA LEE (APSW, SAC-IT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LEE
Last Name:BEHNKE
Suffix:
Gender:F
Credentials:APSW, SAC-IT
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:LEE
Other - Last Name:HAZELWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1230
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-1230
Mailing Address - Country:US
Mailing Address - Phone:920-787-6600
Mailing Address - Fax:920-787-0465
Practice Address - Street 1:230 PARK ST
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-9031
Practice Address - Country:US
Practice Address - Phone:920-787-6550
Practice Address - Fax:920-787-0421
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17649-130101YA0400X
WI127964-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)