Provider Demographics
NPI:1861938631
Name:OBERMANN, TED (CSAC CS-IT)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:OBERMANN
Suffix:
Gender:M
Credentials:CSAC CS-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 364
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-0364
Mailing Address - Country:US
Mailing Address - Phone:360-513-0546
Mailing Address - Fax:
Practice Address - Street 1:106 GALVIN RD.
Practice Address - Street 2:
Practice Address - City:ABBOTSFORD
Practice Address - State:WI
Practice Address - Zip Code:54405
Practice Address - Country:US
Practice Address - Phone:715-223-0480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15731132101YA0400X
WI15546133101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)