Basic Information
| Provider Information | |||||||||
| NPI: | 1518070911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RHODES | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. LMFT, LCSW,LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RHODES | ||||||||
| OtherFirstName: | MARILYN | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S. LMFT,LCSW,LPC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 888 THACKERAY TR. | ||||||||
| Address2: | SUITE105 | ||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625423255 | ||||||||
| FaxNumber: | 2625675451 | ||||||||
| Practice Location | |||||||||
| Address1: | 888 THACKERAY TRL STE 105 | ||||||||
| Address2: | 888 THACKERAY TR. SUITE105 | ||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530664342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625423255 | ||||||||
| FaxNumber: | 2625675451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 495125 | WI | X | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | 3836123 | WI | X | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | 172124 | WI | X | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 39261600 | 05 | WI | MEDICAID |