Provider Demographics
NPI:1922548817
Name:PROEBER, LYNNELLEN (SAC)
Entity Type:Individual
Prefix:
First Name:LYNNELLEN
Middle Name:
Last Name:PROEBER
Suffix:
Gender:F
Credentials:SAC
Other - Prefix:MS
Other - First Name:LYNNELLEN
Other - Middle Name:
Other - Last Name:PROEBER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SAC
Mailing Address - Street 1:1610 MILLER PARK WAY
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1610 MILLER PARK WAY
Practice Address - Street 2:
Practice Address - City:WEST MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-3604
Practice Address - Country:US
Practice Address - Phone:414-672-3801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16794-130101YA0400X
WI16135-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)