Provider Demographics
NPI:1336299817
Name:DETTLAFF, RICHARD R (BS,CSAC)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:R
Last Name:DETTLAFF
Suffix:
Gender:M
Credentials:BS,CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W168S7024 PARKLAND DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-9441
Mailing Address - Country:US
Mailing Address - Phone:414-422-4707
Mailing Address - Fax:
Practice Address - Street 1:514 RIVERVIEW AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3631
Practice Address - Country:US
Practice Address - Phone:262-548-7666
Practice Address - Fax:262-548-7656
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1355101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)