Healthcare Provider Details

I. General information

NPI: 1679095814
Provider Name (Legal Business Name): MELISSA PTACEK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA KELLY

II. Dates (important events)

Enumeration Date: 07/10/2017
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15850 W BLUEMOUND RD STE 208
BROOKFIELD WI
53005-6007
US

IV. Provider business mailing address

15850 W BLUEMOUND RD
BROOKFIELD WI
53005-6022
US

V. Phone/Fax

Practice location:
  • Phone: 262-719-3824
  • Fax:
Mailing address:
  • Phone: 262-719-3824
  • Fax: 262-641-9040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6171-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: