Provider Demographics
NPI:1407029952
Name:PELMAN, MARY KATHRYN (MS, LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:PELMAN
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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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:
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:2008-04-04
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4143-125101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40943200Medicaid