Basic Information
| Provider Information | |||||||||
| NPI: | 1780994731 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DABETIC | ||||||||
| FirstName: | BOJAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | SAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3113 E WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537044330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082420220 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3113 E WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537044330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082420220 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2010 | ||||||||
| LastUpdateDate: | 10/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 14672-131 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.