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General NPI Number Information
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NPI Number | 1407349657
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Entity Type | Organization
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Legal Business Name | UNMASKED EXPRESSIVE THERAPIES
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Dates
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Enumeration Date | 06/12/2018
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Last Update Date | 11/05/2024
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Provider Practice Location Address
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Address Line | 207 N SPRING ST
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City | BEAVER DAM
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State | WI
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Zip | 53916-2115
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Country | US
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Telephone | 920-219-9448
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Fax |
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Provider Business Mailing Address
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Address Line | 209 S UNIVERSITY AVE STE 1
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City | BEAVER DAM
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State | WI
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Zip | 53916-2464
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Country | US
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Telephone | 920-219-9448
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | TAMI JOE DELISLE
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Credential | ATR-BC, LPC
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Telephone | 920-382-0445
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 6745-125
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License Number State | WI
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