Provider Demographics
NPI:1730129636
Name:LUZNICKY, JOHN K (CSAC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:K
Last Name:LUZNICKY
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 1:6510 W LAYTON AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4573
Mailing Address - Country:US
Mailing Address - Phone:414-763-7751
Mailing Address - Fax:414-763-7755
Practice Address - Street 1:6510 W LAYTON AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4573
Practice Address - Country:US
Practice Address - Phone:414-763-7751
Practice Address - Fax:414-763-7755
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14240101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1679951057Medicaid