Provider Demographics
NPI:1942253315
Name:WICHLACZ, RAEANN (CADC III)
Entity Type:Individual
Prefix:MRS
First Name:RAEANN
Middle Name:
Last Name:WICHLACZ
Suffix:
Gender:F
Credentials:CADC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 GALVIN ROAD
Mailing Address - Street 2:P.O. BOX 447
Mailing Address - City:ABBOTSFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54405
Mailing Address - Country:US
Mailing Address - Phone:175-223-0480
Mailing Address - Fax:715-223-1611
Practice Address - Street 1:106 GALVIN ROAD
Practice Address - Street 2:
Practice Address - City:ABBOTSFORD
Practice Address - State:WI
Practice Address - Zip Code:54405
Practice Address - Country:US
Practice Address - Phone:175-223-0480
Practice Address - Fax:715-223-1611
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11042101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39380400Medicaid