Provider Demographics
NPI:1962818542
Name:DELAGARZA, TIODOLO III (SAC-IT)
Entity Type:Individual
Prefix:
First Name:TIODOLO
Middle Name:
Last Name:DELAGARZA
Suffix:III
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-2301
Mailing Address - Country:US
Mailing Address - Phone:414-643-8530
Mailing Address - Fax:414-647-8602
Practice Address - Street 1:1111 S 6TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-2301
Practice Address - Country:US
Practice Address - Phone:414-643-8530
Practice Address - Fax:414-647-8602
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17036-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)