Provider Demographics
NPI:1497767040
Name:BRONECKI, RICHARD J (LISW, CEAP, SAP)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:BRONECKI
Suffix:
Gender:M
Credentials:LISW, CEAP, SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 E CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-2214
Mailing Address - Country:US
Mailing Address - Phone:262-623-1033
Mailing Address - Fax:
Practice Address - Street 1:108 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2110
Practice Address - Country:US
Practice Address - Phone:920-887-8751
Practice Address - Fax:920-922-7440
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3034123104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39241100Medicaid