Provider Demographics
NPI:1356621072
Name:IZZO, MICHAEL (LCSW, LAC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:IZZO
Suffix:
Gender:M
Credentials:LCSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 W SPENCER ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-4015
Mailing Address - Country:US
Mailing Address - Phone:920-735-9010
Mailing Address - Fax:920-735-9050
Practice Address - Street 1:4000 W SPENCER ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-4015
Practice Address - Country:US
Practice Address - Phone:920-735-9010
Practice Address - Fax:920-735-9050
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15586132101YA0400X
WI77621231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)