Provider Demographics
NPI:1205830965
Name:BRONECKI, ROBERTA A (LCSW)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:A
Last Name:BRONECKI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:A
Other - Last Name:TESAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:PO BOX 359
Mailing Address - Street 2:
Mailing Address - City:MAUSTON
Mailing Address - State:WI
Mailing Address - Zip Code:53948-0359
Mailing Address - Country:US
Mailing Address - Phone:608-847-7575
Mailing Address - Fax:608-847-3096
Practice Address - Street 1:124 GRAYSIDE AVE
Practice Address - Street 2:
Practice Address - City:MAUSTON
Practice Address - State:WI
Practice Address - Zip Code:53948-1913
Practice Address - Country:US
Practice Address - Phone:608-847-7575
Practice Address - Fax:608-847-3096
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI71631041C0700X
WI7163-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11988111OtherCAQH
WI40983800Medicaid
WI1013375104OtherAGENCY NPI NUMBER