Basic Information
| Provider Information | |||||||||
| NPI: | 1548251655 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZIPPERER | ||||||||
| FirstName: | GLENN | ||||||||
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| Credential: | LCSW CADC III | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 994 | ||||||||
| Address2: | STE 350 | ||||||||
| City: | PORT WASHINGTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530740994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622848130 | ||||||||
| FaxNumber: | 2622848104 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 W MAIN ST | ||||||||
| Address2: | STE 350 | ||||||||
| City: | PORT WASHINGTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530741813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622848130 | ||||||||
| FaxNumber: | 2622848130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1105 | WI | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 2320123 | WI | X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 39333800 | 05 | WI | MEDICAID |