Provider Demographics
NPI:1598386583
Name:ERTL, BRENDA JANE (LPC)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JANE
Last Name:ERTL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:JANE
Other - Last Name:ERTL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 633
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467-0633
Mailing Address - Country:US
Mailing Address - Phone:608-403-8839
Mailing Address - Fax:
Practice Address - Street 1:420 3RD ST S
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-4350
Practice Address - Country:US
Practice Address - Phone:715-712-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-30
Last Update Date:2023-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101356-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100101179Medicaid