Provider Demographics
NPI:1205993482
Name:ZAKUTANSKY, THERESA JOAN (MSW)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:JOAN
Last Name:ZAKUTANSKY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:GRACYALNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:910 ELM GROVE RD STE 11B
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2531
Mailing Address - Country:US
Mailing Address - Phone:262-780-1001
Mailing Address - Fax:262-780-1002
Practice Address - Street 1:910 ELM GROVE RD STE 11B
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2531
Practice Address - Country:US
Practice Address - Phone:262-780-1001
Practice Address - Fax:262-780-1002
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1941-1231041C0700X
WI383-124106H00000X
WI1828-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1205993482Medicaid
1205993482Medicare NSC