Provider Demographics
NPI:1629132840
Name:DETTLAFF, MARIBETH ROSE (MSW, LCSW, CADC)
Entity Type:Individual
Prefix:
First Name:MARIBETH
Middle Name:ROSE
Last Name:DETTLAFF
Suffix:
Gender:F
Credentials:MSW, LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W168S7024 PARKLAND DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-9441
Mailing Address - Country:US
Mailing Address - Phone:414-422-0708
Mailing Address - Fax:
Practice Address - Street 1:500 RIVERVIEW AVE STE 2
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3632
Practice Address - Country:US
Practice Address - Phone:262-548-7399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12548101YA0400X
WI521-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39572300OtherT-19 PROVIDER NUMBER