Healthcare Provider Details

I. General information

NPI: 1750774766
Provider Name (Legal Business Name): MEQUON CLINICAL ASSOCIATES, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2015
Last Update Date: 03/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 W GLEN OAKS LN SUITE 1
MEQUON WI
53092-3467
US

IV. Provider business mailing address

1045 W GLEN OAKS LN SUITE 1
MEQUON WI
53092-3467
US

V. Phone/Fax

Practice location:
  • Phone: 262-241-7778
  • Fax:
Mailing address:
  • Phone: 262-241-7778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2428-226
License Number StateWI

VIII. Authorized Official

Name: DR. JEFFREY TAXMAN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 262-241-7778