Provider Demographics
NPI:1508840992
Name:RAEANN WICHLACZ
Entity Type:Organization
Organization Name:RAEANN WICHLACZ
Other - Org Name:COURAGE TO CHANGE RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RAEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:WICHLACZ
Authorized Official - Suffix:
Authorized Official - Credentials:CADC III
Authorized Official - Phone:715-223-0480
Mailing Address - Street 1:PO BOX 447
Mailing Address - Street 2:106 GALVIN ROAD
Mailing Address - City:ABBOTSFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54405
Mailing Address - Country:US
Mailing Address - Phone:715-223-0480
Mailing Address - Fax:715-223-1611
Practice Address - Street 1:106 GALVIN ROAD
Practice Address - Street 2:
Practice Address - City:ABBOTSFORD
Practice Address - State:WI
Practice Address - Zip Code:54405
Practice Address - Country:US
Practice Address - Phone:715-223-0480
Practice Address - Fax:715-223-1611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11042101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42215300Medicaid
WI000044500Medicare PIN