Healthcare Provider Details

I. General information

NPI: 1982437695
Provider Name (Legal Business Name): EMILY ANN PETERSDORFF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY ANN MCCULLOH

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 FOREST GROVE DR STE 207A
PEWAUKEE WI
53072-3738
US

IV. Provider business mailing address

285 FOREST GROVE DR STE 207A
PEWAUKEE WI
53072-3738
US

V. Phone/Fax

Practice location:
  • Phone: 608-352-0337
  • Fax:
Mailing address:
  • Phone: 608-352-0337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number135459
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: