Provider Demographics
NPI:1780262840
Name:ERTMAN, TRISTAN ALBERT (SAC-IT)
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:ALBERT
Last Name:ERTMAN
Suffix:
Gender:M
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 1:530 STATE ROAD 67
Mailing Address - Street 2:
Mailing Address - City:KIEL
Mailing Address - State:WI
Mailing Address - Zip Code:53042-1650
Mailing Address - Country:US
Mailing Address - Phone:920-894-1374
Mailing Address - Fax:920-894-1373
Practice Address - Street 1:530 STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:KIEL
Practice Address - State:WI
Practice Address - Zip Code:53042-1650
Practice Address - Country:US
Practice Address - Phone:920-894-1374
Practice Address - Fax:920-894-1373
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19029-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI46-1566338OtherPATHWAYS TO A BETTER LIFE