Provider Demographics
NPI:1619633542
Name:WOLLECK, MADISEN MARIE
Entity Type:Individual
Prefix:
First Name:MADISEN
Middle Name:MARIE
Last Name:WOLLECK
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 1:13441 WOLF RD
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95949-8127
Mailing Address - Country:US
Mailing Address - Phone:503-477-0784
Mailing Address - Fax:
Practice Address - Street 1:500 CROWN POINT CIR
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9561
Practice Address - Country:US
Practice Address - Phone:530-265-5811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator