Provider Demographics
NPI:1710740691
Name:PRESTIGIACOMO, ABBY ROSE
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:ROSE
Last Name:PRESTIGIACOMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3936 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-9187
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3936 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:HOLMEN
Practice Address - State:WI
Practice Address - Zip Code:54636-9187
Practice Address - Country:US
Practice Address - Phone:608-315-4706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician