Provider Demographics
NPI:1053581660
Name:BACCHUS, FRANK AUSTIN (M DIV)
Entity type:Individual
Prefix:MR
First Name:FRANK
Middle Name:AUSTIN
Last Name:BACCHUS
Suffix:
Gender:M
Credentials:M DIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 S AMOR DR
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53146-2309
Mailing Address - Country:US
Mailing Address - Phone:262-521-3000
Mailing Address - Fax:262-521-3371
Practice Address - Street 1:2925 S AMOR DR
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53146-2309
Practice Address - Country:US
Practice Address - Phone:262-521-3000
Practice Address - Fax:262-521-3371
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI225124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist