Healthcare Provider Details

I. General information

NPI: 1972448371
Provider Name (Legal Business Name): BLAKE STAUTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 RAYOVAC DR #103
MADISON WI
53711
US

IV. Provider business mailing address

W9605 IVAN ST
CAMBRIDGE WI
53523-9021
US

V. Phone/Fax

Practice location:
  • Phone: 608-238-5826
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: