Provider Demographics
NPI:1801819552
Name:DILLENBURG, MICHAEL (MS, CADC III)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DILLENBURG
Suffix:
Gender:M
Credentials:MS, CADC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 N JANACEK RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-6102
Mailing Address - Country:US
Mailing Address - Phone:262-641-9050
Mailing Address - Fax:262-641-9126
Practice Address - Street 1:4325 S 60TH ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-3508
Practice Address - Country:US
Practice Address - Phone:414-546-0467
Practice Address - Fax:414-546-0678
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI591101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43558400Medicaid