Basic Information
| Provider Information | |||||||||
| NPI: | 1760868939 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SLEITER | ||||||||
| FirstName: | TISHA | ||||||||
| MiddleName: | DAWN | ||||||||
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| Credential: | MSW, APSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MARATHON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544488800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153215444 | ||||||||
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| Practice Location | |||||||||
| Address1: | 143 S GIBSON ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544511622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157482121 | ||||||||
| FaxNumber: | 7157487595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2015 | ||||||||
| LastUpdateDate: | 01/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 130572-121 | WI | N | Behavioral Health & Social Service Providers | Social Worker | 106H00000X | 130572-121 | WI | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.