Provider Demographics
NPI:1790257525
Name:WITHERSPOON, TONYA ILIAH (LPC, CSAC)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:ILIAH
Last Name:WITHERSPOON
Suffix:
Gender:F
Credentials:LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1978
Mailing Address - Country:US
Mailing Address - Phone:262-687-2222
Mailing Address - Fax:
Practice Address - Street 1:1320 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1978
Practice Address - Country:US
Practice Address - Phone:262-687-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16327-132101YA0400X
WI6978-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)