Provider Demographics
NPI:1306067376
Name:WIERSCHKE, MARK ALAN (MS, LPC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:WIERSCHKE
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 WAGON DR.
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669
Mailing Address - Country:US
Mailing Address - Phone:608-786-4475
Mailing Address - Fax:
Practice Address - Street 1:319 MAIN ST.
Practice Address - Street 2:SUITE 302
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601
Practice Address - Country:US
Practice Address - Phone:608-796-1168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3284-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40960900Medicaid