Provider Demographics
NPI:1386631158
Name:BEFERA-ZIELINSKI, MARILYN S (PHD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:S
Last Name:BEFERA-ZIELINSKI
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 1:1244 WISCONSIN AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1987
Mailing Address - Country:US
Mailing Address - Phone:262-635-5520
Mailing Address - Fax:262-635-5530
Practice Address - Street 1:1244 WISCONSIN AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1987
Practice Address - Country:US
Practice Address - Phone:262-635-5520
Practice Address - Fax:262-635-5530
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1619-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39272900Medicaid
WI000352430Medicare ID - Type Unspecified