Provider Demographics
NPI:1356675813
Name:VON BRIESEN, MARGARET D (PHD)
Entity Type:Individual
Prefix:
First Name:MARGARET
Middle Name:D
Last Name:VON BRIESEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:D
Other - Last Name:VON BRIESEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PH, D
Mailing Address - Street 1:320 E JUNEAU ST
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-2626
Mailing Address - Country:US
Mailing Address - Phone:608-567-0301
Mailing Address - Fax:608-372-1224
Practice Address - Street 1:500 E VETERANS ST
Practice Address - Street 2:116 B
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-3105
Practice Address - Country:US
Practice Address - Phone:608-372-3971
Practice Address - Fax:608-372-1224
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2852-057103T00000X
IL071007861103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist