MEDICARE: MELISSA PTACEK LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	6171-125	WI

General Provider Information

NPI Number	:	1679095814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA PTACEK LPC

Provider Business Mailing Address
First Line	:	15850 W BLUEMOUND RD
Second Line	:
City	:	BROOKFIELD
State	:	WI
Zip	:	53005-6022
Country	:	US
Telephone Number	:	262-719-3824
Fax Number	:	262-641-9040

Provider Business Practice Location Address
First Line	:	15850 W BLUEMOUND RD STE 208
Second Line	:
City	:	BROOKFIELD
State	:	WI
Zip	:	53005-6007
Country	:	US
Telephone Number	:	262-719-3824
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2017
Last Update Date	:	12/18/2018

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