Basic Information
| Provider Information | |||||||||
| NPI: | 1710309059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREEMAN | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | JACOB | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW, CSAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1035 W GLEN OAKS LN STE 110 | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530923392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622446177 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17100 W NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530054436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622446177 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2014 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 17043-130 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 16116-132 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 8678-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.