Provider Demographics
NPI:1861521403
Name:WALLNER, MICHAEL LEO (MS, LPC, NCC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LEO
Last Name:WALLNER
Suffix:
Gender:M
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 N HINE AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-4316
Mailing Address - Country:US
Mailing Address - Phone:414-659-1194
Mailing Address - Fax:414-442-1775
Practice Address - Street 1:6040 W LISBON AVE STE 103
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2116
Practice Address - Country:US
Practice Address - Phone:414-442-1751
Practice Address - Fax:414-442-1775
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3935-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43703400Medicaid