Provider Demographics
NPI:1821431099
Name:LUEDKE, TYLER G (SAC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:G
Last Name:LUEDKE
Suffix:
Gender:M
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 GERSHWIN DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-4328
Mailing Address - Country:US
Mailing Address - Phone:920-391-4740
Mailing Address - Fax:920-391-4740
Practice Address - Street 1:3150 GERSHWIN DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-4328
Practice Address - Country:US
Practice Address - Phone:920-391-6964
Practice Address - Fax:920-391-4731
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15877-131101YA0400X
WI131735-121104100000X
WI10068-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1528098530Medicaid