Healthcare Provider Details

I. General information

NPI: 1427611524
Provider Name (Legal Business Name): MARA NICOLE ULESICH LPC, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 NORTHWESTERN AVE S
STILLWATER MN
55082-7534
US

IV. Provider business mailing address

312 WALNUT LN
SOMERSET WI
54025-1200
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-4840
  • Fax:
Mailing address:
  • Phone: 715-514-9760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12297-125
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5601
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: