Provider Demographics
NPI:1619618071
Name:PASKE, LAURA MAE (SAC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MAE
Last Name:PASKE
Suffix:
Gender:F
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 S TELULAH AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-3422
Mailing Address - Country:US
Mailing Address - Phone:920-889-3239
Mailing Address - Fax:
Practice Address - Street 1:1095 MIDWAY RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1115
Practice Address - Country:US
Practice Address - Phone:920-720-2300
Practice Address - Fax:920-720-3719
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16555101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty