Healthcare Provider Details

I. General information

NPI: 1194065086
Provider Name (Legal Business Name): ELLYN JEAN ZOGRAFI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2013
Last Update Date: 11/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1147 E GORHAM ST
MADISON WI
53703-1609
US

IV. Provider business mailing address

1147 E GORHAM ST
MADISON WI
53703-1609
US

V. Phone/Fax

Practice location:
  • Phone: 608-772-1656
  • Fax:
Mailing address:
  • Phone: 608-772-1656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1027-124
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: