Provider Demographics
NPI:1336785336
Name:LETTEER, SELENA L (LPC, CSAC, ICS)
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:L
Last Name:LETTEER
Suffix:
Gender:F
Credentials:LPC, CSAC, ICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7957 W WIND LAKE RD STE E
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-2234
Mailing Address - Country:US
Mailing Address - Phone:608-561-8656
Mailing Address - Fax:
Practice Address - Street 1:7957 W WIND LAKE RD STE E
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:WI
Practice Address - Zip Code:53185-2234
Practice Address - Country:US
Practice Address - Phone:608-561-8656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7262-125101YP2500X
WI18405-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100095395Medicaid