Basic Information
Provider Information | |||||||||
NPI: | 1285067413 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEDVINA | ||||||||
FirstName: | JOANNA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW, LCSW, CSAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16535 W BLUEMOUND RD STE 200 | ||||||||
Address2: |   | ||||||||
City: | BROOKFIELD | ||||||||
State: | WI | ||||||||
PostalCode: | 530055906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2625423255 | ||||||||
FaxNumber: | 2628216180 | ||||||||
Practice Location | |||||||||
Address1: | 4811 S 76TH ST STE 208 | ||||||||
Address2: |   | ||||||||
City: | GREENFIELD | ||||||||
State: | WI | ||||||||
PostalCode: | 532204352 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2625423255 | ||||||||
FaxNumber: | 4148170442 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2013 | ||||||||
LastUpdateDate: | 08/12/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 15649-132 | WI | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 8033-123 | WI | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.