Provider Demographics
NPI:1538924501
Name:VISCONTI, BIANCA MARIA
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:MARIA
Last Name:VISCONTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-2857
Mailing Address - Country:US
Mailing Address - Phone:224-419-2014
Mailing Address - Fax:
Practice Address - Street 1:917 SHERWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-2224
Practice Address - Country:US
Practice Address - Phone:224-419-2014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI104100000X
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician