Provider Demographics
NPI:1609416411
Name:OPGENORTH, RICKELLE AUDRIS
Entity Type:Individual
Prefix:
First Name:RICKELLE
Middle Name:AUDRIS
Last Name:OPGENORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 MARK AVE
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-1199
Mailing Address - Country:US
Mailing Address - Phone:608-377-7487
Mailing Address - Fax:
Practice Address - Street 1:1216 MARK AVE
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-1199
Practice Address - Country:US
Practice Address - Phone:608-377-7487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4829-226101YP2500X
WI390200000X
WI4829-26101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI473326066Medicaid