Provider Demographics
NPI:1407245335
Name:PARKER, LANNY (CSAC)
Entity Type:Individual
Prefix:
First Name:LANNY
Middle Name:
Last Name:PARKER
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 GALVIN RD.
Mailing Address - Street 2:
Mailing Address - City:ABBOTSFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54405
Mailing Address - Country:US
Mailing Address - Phone:715-223-0480
Mailing Address - Fax:715-223-1611
Practice Address - Street 1:106 GALVIN ROAD
Practice Address - Street 2:
Practice Address - City:ABBOTSFORD
Practice Address - State:WI
Practice Address - Zip Code:54405
Practice Address - Country:US
Practice Address - Phone:715-223-0480
Practice Address - Fax:715-223-1611
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1610-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)