Provider Demographics
NPI:1811101421
Name:WILTZIUS, DAVID F (LPC)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:F
Last Name:WILTZIUS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 3RD ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4418
Mailing Address - Country:US
Mailing Address - Phone:920-921-3343
Mailing Address - Fax:920-921-0989
Practice Address - Street 1:196 3RD ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4418
Practice Address - Country:US
Practice Address - Phone:920-921-3343
Practice Address - Fax:920-921-0989
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI780-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional