1851668669 NPI number — MRS. MICHELE MARIE MASTALARZ MSW, LCSW

Table of content: MRS. MICHELE MARIE MASTALARZ MSW, LCSW (NPI 1851668669)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851668669 NPI number — MRS. MICHELE MARIE MASTALARZ MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASTALARZ
Provider First Name:
MICHELE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851668669
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
207 E BUFFALO ST
Provider Second Line Business Mailing Address:
SUITE 510
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-262-3751
Provider Business Mailing Address Fax Number:
414-262-3751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 E BUFFALO ST
Provider Second Line Business Practice Location Address:
SUITE 510
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53202-5739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-375-1116
Provider Business Practice Location Address Fax Number:
262-375-1071
Provider Enumeration Date:
11/22/2011

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:  8124-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 104100000X , with the licence number: 128508-121 , 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: 128508-121 . This is a "APSW" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 8124-123 . This is a "STATE OF WI DEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES, LCSW" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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