Healthcare Provider Details

I. General information

NPI: 1548607963
Provider Name (Legal Business Name): KATHERINE MARIE HULBERT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHERINE MARIE MENGLER LCSW

II. Dates (important events)

Enumeration Date: 05/24/2013
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 PARK AVE
BEAVER DAM WI
53916-2205
US

IV. Provider business mailing address

6502 GRAND TETON PLAZA SUITE 206
MADISON WI
53719-1047
US

V. Phone/Fax

Practice location:
  • Phone: 920-887-3171
  • Fax: 920-887-8622
Mailing address:
  • Phone: 608-827-7220
  • Fax: 608-827-7223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7938-123
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.012494
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: