Healthcare Provider Details

I. General information

NPI: 1215868823
Provider Name (Legal Business Name): AUDREY ESHLEMAN-HEAD LPC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 E FOREST ST STE 117
OCONOMOWOC WI
53066-3707
US

IV. Provider business mailing address

3610 FALCON CT
WATERFORD WI
53185-4737
US

V. Phone/Fax

Practice location:
  • Phone: 608-618-1716
  • Fax:
Mailing address:
  • Phone: 262-825-8247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8969-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: