Healthcare Provider Details

I. General information

NPI: 1164332334
Provider Name (Legal Business Name): AUDREY VIVIAN HARBOTT LPC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 S 108TH ST STE 100
HALES CORNERS WI
53130-1321
US

IV. Provider business mailing address

5250 S 108TH ST STE 100
HALES CORNERS WI
53130-1321
US

V. Phone/Fax

Practice location:
  • Phone: 414-296-1730
  • Fax:
Mailing address:
  • Phone: 414-296-1730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9259-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: