Provider Demographics
NPI:1760023014
Name:ADESSO, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:ADESSO
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 1:1124 SILVER BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-3519
Mailing Address - Country:US
Mailing Address - Phone:920-650-0725
Mailing Address - Fax:
Practice Address - Street 1:1011 N LYNNDALE DR STE 2D
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3091
Practice Address - Country:US
Practice Address - Phone:920-944-8118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4487-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIS126281Medicaid