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General NPI Number Information
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NPI Number | 1215368139
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Entity Type | Organization
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Legal Business Name | WISE MIND MENTAL HEALTH CLINIC, LLC
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Dates
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Enumeration Date | 12/02/2013
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Last Update Date | 04/01/2014
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Provider Practice Location Address
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Address Line | 601 E 3RD ST
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City | MARSHFIELD
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State | WI
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Zip | 54449-4512
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Country | US
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Telephone | 715-384-0080
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Fax | 715-384-0090
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Provider Business Mailing Address
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Address Line | 601 E 3RD ST
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City | MARSHFIELD
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State | WI
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Zip | 54449-4512
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Country | US
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Telephone | 715-384-0080
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Fax | 715-384-0090
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Authorized Official
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Title or Position | MEMBER/MANAGER
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Name | PATRICIA KAY FABER
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Credential | MSW
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Telephone | 715-384-0080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 4342
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License Number State | WI
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