Provider Demographics
NPI:1013341221
Name:VELISSARIS, MATTHEW LEE
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LEE
Last Name:VELISSARIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4929 W FOND DU LAC AVE
Mailing Address - Street 2:M
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2324
Mailing Address - Country:US
Mailing Address - Phone:414-871-6122
Mailing Address - Fax:414-871-2552
Practice Address - Street 1:4001 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2530
Practice Address - Country:US
Practice Address - Phone:414-759-5193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1942-226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor