Healthcare Provider Details

I. General information

NPI: 1386116002
Provider Name (Legal Business Name): MEGAN WOJTAK LPC, SAC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 TAYLOR AVE
RACINE WI
53403-2405
US

IV. Provider business mailing address

1717 TAYLOR AVE
RACINE WI
53403-2405
US

V. Phone/Fax

Practice location:
  • Phone: 262-638-6744
  • Fax: 262-638-6540
Mailing address:
  • Phone: 262-638-6744
  • Fax: 262-638-6540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6549-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18512-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: