Basic Information
| Provider Information | |||||||||
| NPI: | 1942937784 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLEASE | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC-IT, ATR-P | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9773 W KEEFE AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532222660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202964474 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 210 W CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147276320 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2022 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 5393-226 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.