Provider Demographics
NPI:1124030770
Name:EKLUND, MARK R (LCSW,MFT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:EKLUND
Suffix:
Gender:M
Credentials:LCSW,MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22040
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2040
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7229
Practice Address - Street 1:1325 ANGELS PATH RD
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-4050
Practice Address - Country:US
Practice Address - Phone:920-338-2855
Practice Address - Fax:920-338-9270
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI485-124106H00000X, 106H00000X
WI1501-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39342800Medicaid
WI000644550Medicare ID - Type Unspecified