Provider Demographics
NPI:1063238574
Name:MENGISTU, CARMEN
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:MENGISTU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 TODD DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-2922
Mailing Address - Country:US
Mailing Address - Phone:612-232-9646
Mailing Address - Fax:
Practice Address - Street 1:2901 W BELTLINE HWY STE 301
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-4228
Practice Address - Country:US
Practice Address - Phone:608-236-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-29
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7384-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical