Healthcare Provider Details

I. General information

NPI: 1588581805
Provider Name (Legal Business Name): BRACKEN BLYTHE FEN HOWARD MSW, APSW
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 N MAIN ST STE 230
RICE LAKE WI
54868-1774
US

IV. Provider business mailing address

802 N WILSON AVE
RICE LAKE WI
54868-1244
US

V. Phone/Fax

Practice location:
  • Phone: 715-246-4840
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number136128-121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: