Provider Demographics
NPI:1447574702
Name:ELLISON, THERESA A (CSAC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:ELLISON
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:A
Other - Last Name:CONSTANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSAC
Mailing Address - Street 1:17230 95TH AVE
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-5189
Mailing Address - Country:US
Mailing Address - Phone:715-896-3555
Mailing Address - Fax:
Practice Address - Street 1:13 BAY ST
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-2437
Practice Address - Country:US
Practice Address - Phone:715-726-9023
Practice Address - Fax:715-726-9055
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13165101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)