Basic Information
| Provider Information | |||||||||
| NPI: | 1760742522 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELEEN | ||||||||
| FirstName: | ROSEMARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CSAC-IT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HETRICK | ||||||||
| OtherFirstName: | ROSEMARY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CSAC-IT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2821 N 4TH ST STE 139 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532122362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142644217 | ||||||||
| FaxNumber: | 4142644218 | ||||||||
| Practice Location | |||||||||
| Address1: | 2821 N 4TH ST STE 139 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532122362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142644217 | ||||||||
| FaxNumber: | 4142644218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2012 | ||||||||
| LastUpdateDate: | 10/29/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 16569-130 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.