Basic Information
| Provider Information | |||||||||
| NPI: | 1255431870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITKOWSKI | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | M.S, , LPC, ICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6314 ODANA RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537191129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082770610 | ||||||||
| FaxNumber: | 6082706651 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 GAMMON LN | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537192210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084178144 | ||||||||
| FaxNumber: | 6084178144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2006 | ||||||||
| LastUpdateDate: | 04/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 4213-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 4213-125 | WI | N | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 14292 | 01 | WI | AODA CREDENTIAL | OTHER | 41 - 226 | 01 | WI | WI DRL, LPC-TRAINING LIC. | OTHER |