Provider Demographics
NPI:1407397938
Name:SERSHON, RYAN (LCSW)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:SERSHON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 W GLEN OAKS LN STE 110
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3392
Mailing Address - Country:US
Mailing Address - Phone:262-244-6178
Mailing Address - Fax:262-299-3040
Practice Address - Street 1:W175N11081 STONEWOOD DR STE 212
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-4771
Practice Address - Country:US
Practice Address - Phone:262-244-6177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-16
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15925101YA0400X
WI85251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI8525-123OtherLCSW
WI1000677057Medicaid