Provider Demographics
NPI:1851881452
Name:HANIZESKI, DAVID ROMAN (LPC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ROMAN
Last Name:HANIZESKI
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 N 51ST BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-3308
Mailing Address - Country:US
Mailing Address - Phone:414-527-6970
Mailing Address - Fax:414-527-6971
Practice Address - Street 1:5555 N 51ST BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-3308
Practice Address - Country:US
Practice Address - Phone:414-527-6970
Practice Address - Fax:414-527-6971
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2769-226171M00000X
WI7587-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator