1366461535 NPI number — PAULETTE M WIJAS YERGES

Table of content: PAULETTE M WIJAS YERGES (NPI 1366461535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366461535 NPI number — PAULETTE M WIJAS YERGES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIJAS YERGES
Provider First Name:
PAULETTE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WIJAS
Provider Other First Name:
PAULETTE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1366461535
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 145
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLANCHARDVILLE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53516-0145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-827-7100
Provider Business Mailing Address Fax Number:
608-827-7101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 S MAIN STREET
Provider Second Line Business Practice Location Address:
P O BOX 145
Provider Business Practice Location Address City Name:
BLANCHARDVILLE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53516-9002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-341-8600
Provider Business Practice Location Address Fax Number:
608-341-8600
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  1932-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YA0400X , with the licence number: 12737 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 39630100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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