Healthcare Provider Details

I. General information

NPI: 1285240499
Provider Name (Legal Business Name): TINA TOLTZIEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 12/30/2023
Certification Date: 12/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2453 ATWOOD AVE STE 101A
MADISON WI
53704-5655
US

IV. Provider business mailing address

2453 ATWOOD AVE STE 101A
MADISON WI
53704-5655
US

V. Phone/Fax

Practice location:
  • Phone: 608-692-1202
  • Fax:
Mailing address:
  • Phone: 608-218-1533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11510
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: