Provider Demographics
NPI:1497883888
Name:USTIANOWSKI, PATRICIA A (CADCIII)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:A
Last Name:USTIANOWSKI
Suffix:
Gender:F
Credentials:CADCIII
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:A
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADCIII
Mailing Address - Street 1:P.O. BOX 189
Mailing Address - Street 2:533 PEACE PIPE ROAD
Mailing Address - City:LAC DU FLAMBEAU
Mailing Address - State:WI
Mailing Address - Zip Code:54538-0189
Mailing Address - Country:US
Mailing Address - Phone:715-588-1511
Mailing Address - Fax:715-588-3903
Practice Address - Street 1:533 PEACE PIPE ROAD
Practice Address - Street 2:
Practice Address - City:LAC DU FLAMBEAU
Practice Address - State:WI
Practice Address - Zip Code:54538-0189
Practice Address - Country:US
Practice Address - Phone:715-588-1511
Practice Address - Fax:715-588-3903
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1765101YA0400X
WI13667101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39351000Medicaid