=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134618655
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH WAHL MSSW, CAPSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2018
-----------------------------------------------------
Last Update Date | 05/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 EAST OLIN AVENUE SUITE 100
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53713-1467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-252-1320
-----------------------------------------------------
Fax | 608-252-1333
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 EAST OLIN AVENUE SUITE 100
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53713-1467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-252-1320
-----------------------------------------------------
Fax | 608-252-1333
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 127535-121
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------