Healthcare Provider Details

I. General information

NPI: 1902624182
Provider Name (Legal Business Name): ARDEN DANIEL BUBULA LPC-IT
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 BEAR CLAW WAY APT 308
MADISON WI
53717-2775
US

IV. Provider business mailing address

742 BEAR CLAW WAY APT 308
MADISON WI
53717-2775
US

V. Phone/Fax

Practice location:
  • Phone: 847-340-0422
  • Fax:
Mailing address:
  • Phone: 847-340-0422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8016-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: