Provider Demographics
NPI:1114739398
Name:BLANCK, MATTISON
Entity type:Individual
Prefix:
First Name:MATTISON
Middle Name:
Last Name:BLANCK
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 1:1125 N 9TH ST APT 327
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-1437
Mailing Address - Country:US
Mailing Address - Phone:224-430-6707
Mailing Address - Fax:
Practice Address - Street 1:9401 W BELOIT RD STE 201
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-4357
Practice Address - Country:US
Practice Address - Phone:414-380-3001
Practice Address - Fax:414-775-2734
Is Sole Proprietor?:No
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health