Provider Demographics
NPI:1700279619
Name:VACHA, RHEA L (LCSW)
Entity Type:Individual
Prefix:
First Name:RHEA
Middle Name:L
Last Name:VACHA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:RHEA
Other - Middle Name:L
Other - Last Name:ELLESTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAPSW
Mailing Address - Street 1:742 CRESTHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53527-9677
Mailing Address - Country:US
Mailing Address - Phone:608-513-9637
Mailing Address - Fax:
Practice Address - Street 1:30 W MIFFLIN ST STE 502
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-2589
Practice Address - Country:US
Practice Address - Phone:608-513-9637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-17
Last Update Date:2024-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9393-1231041C0700X
WI129639-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1700279619Medicaid