Healthcare Provider Details

I. General information

NPI: 1457046807
Provider Name (Legal Business Name): MORGAN PROVO LPC-IT, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 W MEQUON RD
MEQUON WI
53092-3254
US

IV. Provider business mailing address

4041 N OAKLAND AVE APT 304
SHOREWOOD WI
53211-2386
US

V. Phone/Fax

Practice location:
  • Phone: 414-292-4242
  • Fax: 262-240-9745
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9124-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: