Provider Demographics
NPI:1497482632
Name:WITTROCK, JOAN M
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:WITTROCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 BROADWAY ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-2488
Mailing Address - Country:US
Mailing Address - Phone:608-774-8556
Mailing Address - Fax:
Practice Address - Street 1:414 BROADWAY ST STE 1
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-2488
Practice Address - Country:US
Practice Address - Phone:608-774-8556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7053-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health