Provider Demographics
NPI:1659546745
Name:LEMON, WALTER (CSAC)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:
Last Name:LEMON
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 N 4TH ST
Mailing Address - Street 2:SUITE 139
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2362
Mailing Address - Country:US
Mailing Address - Phone:414-264-4217
Mailing Address - Fax:414-264-4218
Practice Address - Street 1:2821 N 4TH ST
Practice Address - Street 2:SUITE 139
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2362
Practice Address - Country:US
Practice Address - Phone:414-264-4217
Practice Address - Fax:414-264-4218
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11343-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39173800Medicaid