Provider Demographics
NPI:1821263849
Name:TEGTMEIER, MARK ALAN (MA, LCSW, LPC, LMFT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:TEGTMEIER
Suffix:
Gender:M
Credentials:MA, LCSW, LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E7475 RAWHIDE RD
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961
Mailing Address - Country:US
Mailing Address - Phone:920-982-6100
Mailing Address - Fax:920-982-5040
Practice Address - Street 1:E7475 RAWHIDE RD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961
Practice Address - Country:US
Practice Address - Phone:920-982-6100
Practice Address - Fax:920-982-5040
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1863-125101YP2500X
WI2364-1231041C0700X
WI479-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39273400Medicaid