Provider Demographics
NPI:1295234805
Name:VANLOO, BREANNE MARIE (SAC-IT)
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:MARIE
Last Name:VANLOO
Suffix:
Gender:F
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 1:310 W MACKIE ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1638
Mailing Address - Country:US
Mailing Address - Phone:608-250-2512
Mailing Address - Fax:
Practice Address - Street 1:151 E BADGER RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-2708
Practice Address - Country:US
Practice Address - Phone:608-250-2512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18375-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)