Provider Demographics
NPI:1861018863
Name:JUHL, MARDY
Entity Type:Individual
Prefix:
First Name:MARDY
Middle Name:
Last Name:JUHL
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MARDY
Other - Middle Name:ELLIS
Other - Last Name:JUHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MARDY JUHL GOLDSMITH
Mailing Address - Street 1:514 RIVERVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3631
Mailing Address - Country:US
Mailing Address - Phone:262-970-6672
Mailing Address - Fax:
Practice Address - Street 1:514 RIVERVIEW AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3631
Practice Address - Country:US
Practice Address - Phone:262-970-6672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15743101YA0400X
WI15486101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)