Basic Information
Provider Information | |||||||||
NPI: | 1548607963 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HULBERT | ||||||||
FirstName: | KATHERINE | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MENGLER | ||||||||
OtherFirstName: | KATHERINE | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6502 GRAND TETON PLAZA SUITE 206 | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | WI | ||||||||
PostalCode: | 537191047 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6088277220 | ||||||||
FaxNumber: | 6088277223 | ||||||||
Practice Location | |||||||||
Address1: | 809 PARK AVE | ||||||||
Address2: |   | ||||||||
City: | BEAVER DAM | ||||||||
State: | WI | ||||||||
PostalCode: | 539162205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9208873171 | ||||||||
FaxNumber: | 9208878622 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2013 | ||||||||
LastUpdateDate: | 08/27/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 7938-123 | WI | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 149.012494 | IL | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.