Provider Demographics
NPI:1801188271
Name:WHEELER, DARRYL RAY (CSAC)
Entity Type:Individual
Prefix:MR
First Name:DARRYL
Middle Name:RAY
Last Name:WHEELER
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 1:2422 N GRANDVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-6105
Mailing Address - Country:US
Mailing Address - Phone:262-549-6600
Mailing Address - Fax:
Practice Address - Street 1:2979 ALLIED ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5567
Practice Address - Country:US
Practice Address - Phone:262-549-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15393-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)