Healthcare Provider Details

I. General information

NPI: 1851668669
Provider Name (Legal Business Name): MICHELE MARIE MASTALARZ MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 03/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 E BUFFALO ST SUITE 510
MILWAUKEE WI
53202-5739
US

IV. Provider business mailing address

207 E BUFFALO ST SUITE 510
MILWAUKEE WI
53202
US

V. Phone/Fax

Practice location:
  • Phone: 262-375-1116
  • Fax: 262-375-1071
Mailing address:
  • Phone: 414-262-3751
  • Fax: 414-262-3751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number128508-121
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8124-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: