Provider Demographics
NPI:1801022850
Name:BANGERT, JUSTIN ROBERT (MFT)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:ROBERT
Last Name:BANGERT
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 WALL ST.
Mailing Address - Street 2:STE #500
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718
Mailing Address - Country:US
Mailing Address - Phone:608-274-8294
Mailing Address - Fax:
Practice Address - Street 1:5310 WALL ST.
Practice Address - Street 2:STE #500
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718
Practice Address - Country:US
Practice Address - Phone:608-274-8294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist