Provider Demographics
NPI:1568617702
Name:WAKEFIELD, MARK EDWARD (MA, MBA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:WAKEFIELD
Suffix:
Gender:M
Credentials:MA, MBA
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 7370
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53707-7370
Mailing Address - Country:US
Mailing Address - Phone:608-223-0017
Mailing Address - Fax:608-223-0019
Practice Address - Street 1:1709 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-1200
Practice Address - Country:US
Practice Address - Phone:608-223-0017
Practice Address - Fax:608-223-0019
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13764132101YA0400X
WI479226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)