Provider Demographics
NPI:1669449922
Name:WOTNOSKE, CHERI L (CSAC)
Entity Type:Individual
Prefix:
First Name:CHERI
Middle Name:L
Last Name:WOTNOSKE
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DARLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53530-1395
Mailing Address - Country:US
Mailing Address - Phone:608-776-4800
Mailing Address - Fax:608-776-4914
Practice Address - Street 1:627 MAIN ST
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53530-1395
Practice Address - Country:US
Practice Address - Phone:608-776-4800
Practice Address - Fax:608-776-4914
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13939101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39169000Medicaid