Provider Demographics
NPI:1669654125
Name:ACEVEDO, ISMAEL (CSAC)
Entity Type:Individual
Prefix:MR
First Name:ISMAEL
Middle Name:
Last Name:ACEVEDO
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 1:4555 W SCHROEDER DR
Mailing Address - Street 2:185
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53223-1475
Mailing Address - Country:US
Mailing Address - Phone:414-586-0222
Mailing Address - Fax:414-586-0236
Practice Address - Street 1:4555 W SCHROEDER DR
Practice Address - Street 2:185
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53223-1475
Practice Address - Country:US
Practice Address - Phone:414-586-0222
Practice Address - Fax:414-586-0236
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1687-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39357400Medicaid