Basic Information
| Provider Information | |||||||||
| NPI: | 1861615759 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAECK | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MS, LPC, SAC-IT | ||||||||
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| Mailing Information | |||||||||
| Address1: | W209 N13497 ROBINHOOD DR. | ||||||||
| Address2: | |||||||||
| City: | RICHFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626280428 | ||||||||
| FaxNumber: | 2626280428 | ||||||||
| Practice Location | |||||||||
| Address1: | 6040 W. LISBON AVE., SUITE 200 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144479890 | ||||||||
| FaxNumber: | 4744479891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 13486-130 | WI | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 3903-125 | WI | X | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 43719800 | 05 | WI | MEDICAID |