Healthcare Provider Details

I. General information

NPI: 1710469812
Provider Name (Legal Business Name): JOLINE MUTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 SKYLINE DR
CEDARBURG WI
53012-9397
US

IV. Provider business mailing address

1575 SKYLINE DR
CEDARBURG WI
53012-9397
US

V. Phone/Fax

Practice location:
  • Phone: 414-847-5722
  • Fax: 414-443-5722
Mailing address:
  • Phone: 414-847-5722
  • Fax: 414-443-5722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number246-140
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: