Provider Demographics
NPI:1750672648
Name:SELLA, ANTONIO G (CAPSW)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:G
Last Name:SELLA
Suffix:
Gender:M
Credentials:CAPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 ALLEN BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-2287
Mailing Address - Country:US
Mailing Address - Phone:608-827-2300
Mailing Address - Fax:608-827-2399
Practice Address - Street 1:2711 ALLEN BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-2287
Practice Address - Country:US
Practice Address - Phone:608-827-2300
Practice Address - Fax:608-827-2399
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7633OtherDEAN HEALTH INSUANCE