Provider Demographics
NPI:1164718151
Name:DELLISE, ANGELA (LPC, CSAC, CS-IT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:DELLISE
Suffix:
Gender:F
Credentials:LPC, CSAC, CS-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 W BROWN DEER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53209-1220
Mailing Address - Country:US
Mailing Address - Phone:414-540-2170
Mailing Address - Fax:
Practice Address - Street 1:6233 DURAND AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4961
Practice Address - Country:US
Practice Address - Phone:262-554-8165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5385-125101YP2500X
WI16057-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)