Basic Information
| Provider Information | |||||||||
| NPI: | 1851954713 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HETTS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | SAC-IT, BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | MADISON EAST CTC | ||||||||
| Address2: | 5109 WORLD DAIRY DR | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537183807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082420220 | ||||||||
| FaxNumber: | 6082230687 | ||||||||
| Practice Location | |||||||||
| Address1: | MADISON EAST CTC | ||||||||
| Address2: | 5109 WORLD DAIRY DR | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537183807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082420220 | ||||||||
| FaxNumber: | 6082230687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2019 | ||||||||
| LastUpdateDate: | 04/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 17413-130 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.