Healthcare Provider Details

I. General information

NPI: 1982118550
Provider Name (Legal Business Name): AMY DES FORGE MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMY WURZER

II. Dates (important events)

Enumeration Date: 11/18/2017
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 RIVERSIDE DR STE 125
GREEN BAY WI
54301-1900
US

IV. Provider business mailing address

2300 RIVERSIDE DR STE 125
GREEN BAY WI
54301-1900
US

V. Phone/Fax

Practice location:
  • Phone: 715-559-8559
  • Fax:
Mailing address:
  • Phone: 715-559-8559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6583-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: