Provider Demographics
NPI:1801621669
Name:VAIL, MARLENE DIANE (LCSW)
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:DIANE
Last Name:VAIL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 S LOWER GARDENS RD
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:WI
Mailing Address - Zip Code:53125-1102
Mailing Address - Country:US
Mailing Address - Phone:262-903-0784
Mailing Address - Fax:
Practice Address - Street 1:1716 FORDEM AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-4604
Practice Address - Country:US
Practice Address - Phone:608-221-3511
Practice Address - Fax:608-221-3514
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11373-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical