Provider Demographics
NPI:1578886586
Name:DALLAS, LORRIE LASHELL (SACIT)
Entity Type:Individual
Prefix:
First Name:LORRIE
Middle Name:LASHELL
Last Name:DALLAS
Suffix:
Gender:F
Credentials:SACIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 W NASH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-3345
Mailing Address - Country:US
Mailing Address - Phone:414-397-9213
Mailing Address - Fax:414-354-7795
Practice Address - Street 1:5600 W BROWN DEER RD
Practice Address - Street 2:SUITE 110
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-2311
Practice Address - Country:US
Practice Address - Phone:414-810-6691
Practice Address - Fax:866-719-3024
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15459 130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)