Provider Demographics
NPI:1790315711
Name:STASZEWSKI, MICHAEL ADAM (SAC-IT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ADAM
Last Name:STASZEWSKI
Suffix:
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 S 60TH ST APT 206
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-3185
Mailing Address - Country:US
Mailing Address - Phone:414-366-7772
Mailing Address - Fax:
Practice Address - Street 1:4550 W BRADLEY RD
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53223-3713
Practice Address - Country:US
Practice Address - Phone:414-371-1600
Practice Address - Fax:414-371-2400
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18712-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)