Healthcare Provider Details

I. General information

NPI: 1073608980
Provider Name (Legal Business Name): TINA L PLOETZ LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 W BROWN DEER RD SUITE 200
BROWN DEER WI
53209
US

IV. Provider business mailing address

3900 W BROWN DEER RD SUITE 200
BROWN DEER WI
53209
US

V. Phone/Fax

Practice location:
  • Phone: 414-540-2170
  • Fax: 414-540-2171
Mailing address:
  • Phone: 414-540-2170
  • Fax: 414-540-2171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3409125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: