Provider Demographics
NPI:1497986079
Name:MCCREADIE, ROBERT M (CSAC, ICS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:MCCREADIE
Suffix:
Gender:M
Credentials:CSAC, ICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-4984
Mailing Address - Country:US
Mailing Address - Phone:262-409-5462
Mailing Address - Fax:
Practice Address - Street 1:5005 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-5439
Practice Address - Country:US
Practice Address - Phone:608-233-2100
Practice Address - Fax:608-233-2101
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15474131101YA0400X
WI15500-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1497986079Medicaid