Healthcare Provider Details

I. General information

NPI: 1760883789
Provider Name (Legal Business Name): NANCY MATELSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2014
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 S WALNUT ST
APPLETON WI
54911-5920
US

IV. Provider business mailing address

410 S WALNUT ST
APPLETON WI
54911-5920
US

V. Phone/Fax

Practice location:
  • Phone: 920-832-4792
  • Fax: 920-832-2185
Mailing address:
  • Phone: 920-832-4792
  • Fax: 920-832-2185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number56328-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: