Healthcare Provider Details

I. General information

NPI: 1871916890
Provider Name (Legal Business Name): MARY KATHLEEN RANSOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2014
Last Update Date: 01/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 E BADGER RD STE A
MADISON WI
53713-2708
US

IV. Provider business mailing address

151 E BADGER RD STE A
MADISON WI
53713-2708
US

V. Phone/Fax

Practice location:
  • Phone: 608-250-2512
  • Fax:
Mailing address:
  • Phone: 608-250-2512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number121594-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: