Provider Demographics
NPI:1679618342
Name:PADRON, LUISA IVELLISSE (RADC I)
Entity Type:Individual
Prefix:
First Name:LUISA
Middle Name:IVELLISSE
Last Name:PADRON
Suffix:
Gender:F
Credentials:RADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3441 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-5015
Mailing Address - Country:US
Mailing Address - Phone:414-383-3398
Mailing Address - Fax:
Practice Address - Street 1:1545 S LAYTON BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-1924
Practice Address - Country:US
Practice Address - Phone:414-671-5920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13971101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)