Provider Demographics
NPI:1215078662
Name:PULVERMACHER, LOIS A (LCSW)
Entity type:Individual
Prefix:
First Name:LOIS
Middle Name:A
Last Name:PULVERMACHER
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 1:101 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6882
Mailing Address - Country:US
Mailing Address - Phone:920-712-4526
Mailing Address - Fax:800-469-0235
Practice Address - Street 1:840 CHALLENGER DR
Practice Address - Street 2:STE 130
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8351
Practice Address - Country:US
Practice Address - Phone:920-712-4526
Practice Address - Fax:800-469-0235
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7302-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40918400Medicaid
WI7302-123OtherLCSW