Provider Demographics
NPI:1083881924
Name:LANDKAMER-TAGATZ, MARY J (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:LANDKAMER-TAGATZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53964-9068
Mailing Address - Country:US
Mailing Address - Phone:608-296-2139
Mailing Address - Fax:
Practice Address - Street 1:161 SPRING ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:WI
Practice Address - Zip Code:53964-9068
Practice Address - Country:US
Practice Address - Phone:608-296-2139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1634 - 1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39675300Medicaid