Provider Demographics
NPI:1295896454
Name:LIKHTEREV, ALLA Y (MD)
Entity type:Individual
Prefix:DR
First Name:ALLA
Middle Name:Y
Last Name:LIKHTEREV
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:WINNEBAGO MENTAL HEALTH INSTITUTE1300 SOUTH DRIVE
Mailing Address - Street 2:1300 SOUTH DRIVE
Mailing Address - City:WINNEBAGO
Mailing Address - State:WI
Mailing Address - Zip Code:54985-0009
Mailing Address - Country:US
Mailing Address - Phone:920-235-4910
Mailing Address - Fax:920-236-2931
Practice Address - Street 1:WINNEBAGO MENTAL HEALTH INSTITUTE 1300 SOUTH DRIVE
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:WI
Practice Address - Zip Code:54985-0009
Practice Address - Country:US
Practice Address - Phone:920-235-4910
Practice Address - Fax:920-236-2931
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2023-03-07
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Provider Licenses
StateLicense IDTaxonomies
WI371442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32282700Medicaid
WI37144OtherLICENSE NUMBER
WIBL4712748OtherDEA
WI636734Medicare UPIN