Provider Demographics
NPI:1598864225
Name:NOVITSKI, ROBERT R (MSE ICSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:R
Last Name:NOVITSKI
Suffix:
Gender:M
Credentials:MSE ICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301
Mailing Address - Country:US
Mailing Address - Phone:920-432-8777
Mailing Address - Fax:920-435-0749
Practice Address - Street 1:735 E WALNUT ST
Practice Address - Street 2:MARRIAGE & FAMILY THERAPY CENTER
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:920-432-8777
Practice Address - Fax:920-435-0749
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3054 1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11493032OtherCAQH