Healthcare Provider Details

I. General information

NPI: 1073148656
Provider Name (Legal Business Name): MARY T PAULI LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W FULTON ST
EDGERTON WI
53534-1876
US

IV. Provider business mailing address

11101 N SHERMAN RD
EDGERTON WI
53534-9002
US

V. Phone/Fax

Practice location:
  • Phone: 608-561-6614
  • Fax: 608-561-6642
Mailing address:
  • Phone: 608-884-3441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.010034
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7545-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: