Provider Demographics
NPI:1417257148
Name:RETTER, ASHLEY MEGAN (BS SAC-IT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MEGAN
Last Name:RETTER
Suffix:
Gender:F
Credentials:BS SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1654 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-2047
Mailing Address - Country:US
Mailing Address - Phone:262-633-5001
Mailing Address - Fax:262-633-2928
Practice Address - Street 1:1654 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-2047
Practice Address - Country:US
Practice Address - Phone:262-633-5001
Practice Address - Fax:262-633-2928
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15819-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)