Basic Information
| Provider Information | |||||||||
| NPI: | 1124030770 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EKLUND | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW,MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22040 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457226 | ||||||||
| FaxNumber: | 9204457229 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 ANGELS PATH RD | ||||||||
| Address2: | |||||||||
| City: | DE PERE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541154050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203382855 | ||||||||
| FaxNumber: | 9203389270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 04/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 485-124 | WI | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 1041C0700X | 1501-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 39342800 | 05 | WI | MEDICAID |