Healthcare Provider Details

I. General information

NPI: 1962942177
Provider Name (Legal Business Name): MARIAH WULFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 UNIVERSITY AVE STE 350
MADISON WI
53703-4925
US

IV. Provider business mailing address

1829 WINDOM WAY
MADISON WI
53704-3351
US

V. Phone/Fax

Practice location:
  • Phone: 262-441-3662
  • Fax:
Mailing address:
  • Phone: 262-441-3662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4477
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: