Provider Demographics
NPI:1205329307
Name:NEITZEL, ALICIA
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:NEITZEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSPORT
Mailing Address - State:WI
Mailing Address - Zip Code:53010-2703
Mailing Address - Country:US
Mailing Address - Phone:920-533-5073
Mailing Address - Fax:
Practice Address - Street 1:23 W SCOTT ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935
Practice Address - Country:US
Practice Address - Phone:920-926-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)