Healthcare Provider Details

I. General information

NPI: 1073426755
Provider Name (Legal Business Name): BETH WILTMAN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 3RD ST
KEWAUNEE WI
54216-1668
US

IV. Provider business mailing address

915 3RD ST
KEWAUNEE WI
54216-1668
US

V. Phone/Fax

Practice location:
  • Phone: 920-388-3230
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: