Provider Demographics
NPI:1679095814
Name:PTACEK, MELISSA (LPC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PTACEK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15850 W BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-6022
Mailing Address - Country:US
Mailing Address - Phone:262-719-3824
Mailing Address - Fax:262-641-9040
Practice Address - Street 1:15850 W BLUEMOUND RD STE 208
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-6007
Practice Address - Country:US
Practice Address - Phone:262-719-3824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6171-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional