Basic Information
| Provider Information | |||||||||
| NPI: | 1407397938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SERSHON | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1035 W GLEN OAKS LN STE 110 | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530923392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622446178 | ||||||||
| FaxNumber: | 2622993040 | ||||||||
| Practice Location | |||||||||
| Address1: | W175N11081 STONEWOOD DR STE 212 | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530224771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622446177 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2017 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 15925 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 8525 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 8525-123 | 01 | WI | LCSW | OTHER | 1000677057 | 05 | WI | MEDICAID |