Healthcare Provider Details

I. General information

NPI: 1356185003
Provider Name (Legal Business Name): MARY HEGEMAN LPC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 WISCONSIN AVE
SHEBOYGAN WI
53081-4147
US

IV. Provider business mailing address

4223 AUTUMN CT APT E206
SHEBOYGAN WI
53081-1256
US

V. Phone/Fax

Practice location:
  • Phone: 920-650-4741
  • Fax:
Mailing address:
  • Phone: 920-650-4741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7914226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: