=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427623040
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AGATHA MROZ M.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2021
-----------------------------------------------------
Last Update Date | 05/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7709 BEAN RD
-----------------------------------------------------
City | WOODRUFF
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54568-9620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-892-0534
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7709 BEAN RD
-----------------------------------------------------
City | WOODRUFF
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54568-9620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-892-0534
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------