Healthcare Provider Details

I. General information

NPI: 1093373136
Provider Name (Legal Business Name): AUTUMN VERSTEGAN MELIAN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. AUTUMN VERSTEGAN EHLINGER

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13000 W BLUEMOUND RD STE 300
ELM GROVE WI
53122-2650
US

IV. Provider business mailing address

13000 W BLUEMOUND RD STE 300
ELM GROVE WI
53122-2650
US

V. Phone/Fax

Practice location:
  • Phone: 262-785-9188
  • Fax:
Mailing address:
  • Phone: 262-785-9188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number8147125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: