Provider Demographics
NPI:1972910362
Name:STELLOH, LARRY (NO 15850-132)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:STELLOH
Suffix:
Gender:M
Credentials:NO 15850-132
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2319 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-1919
Mailing Address - Country:US
Mailing Address - Phone:414-442-2033
Mailing Address - Fax:
Practice Address - Street 1:2319 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-1919
Practice Address - Country:US
Practice Address - Phone:414-442-2033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15850-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)