Basic Information
Provider Information | |||||||||
NPI: | 1396105227 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FILUT | ||||||||
FirstName: | MARIA | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW, APSW, SAC-IT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SELIG | ||||||||
OtherFirstName: | MARIA | ||||||||
OtherMiddleName: | C | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | APSW, SAC-IT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 121 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | PORT WASHINGTON | ||||||||
State: | WI | ||||||||
PostalCode: | 530741813 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2622848200 | ||||||||
FaxNumber: | 2622388103 | ||||||||
Practice Location | |||||||||
Address1: | 121 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | PORT WASHINGTON | ||||||||
State: | WI | ||||||||
PostalCode: | 530741813 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2622848200 | ||||||||
FaxNumber: | 2622388103 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/04/2016 | ||||||||
LastUpdateDate: | 02/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 1041C0700X | 9651-123 | WI | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.