Provider Demographics
NPI:1740466416
Name:STELLICK, MARY JACOBSON (MSE, ECSE)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JACOBSON
Last Name:STELLICK
Suffix:
Gender:F
Credentials:MSE, ECSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3375 W BREWSTER ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-1602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3375 W BREWSTER ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-1602
Practice Address - Country:US
Practice Address - Phone:920-749-5870
Practice Address - Fax:920-749-5874
Is Sole Proprietor?:No
Enumeration Date:2008-01-12
Last Update Date:2008-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI169066171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator