Provider Demographics
NPI:1114278157
Name:WIELGOS, CHRISTINE (LCSW)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:WIELGOS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 W GLEN OAKS LN STE 110
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3392
Mailing Address - Country:US
Mailing Address - Phone:262-244-6177
Mailing Address - Fax:
Practice Address - Street 1:11518 N PORT WASHINGTON RD STE 202
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3443
Practice Address - Country:US
Practice Address - Phone:262-244-6177
Practice Address - Fax:262-299-3040
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0190331041C0700X
WI9464-1231041C0700X
TX1108491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100110201Medicaid