| NPI | 1285208918 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TABITHA BEA WALLENFANG Owner 920-857-8112 |
| Organization Subpart ? | No |
| Primary Taxonomy | 2084P0800X Psychiatry & Neurology, Psychiatry |
| Additional Taxonomies | 207Q00000X Family Medicine |
| Enumeration Date | 2021-05-17 |
| Last Update Date | 2021-05-17 |