Provider Demographics
NPI:1336845817
Name:DETLOR, MAKENA LIZABETH (LPC-IT)
Entity type:Individual
Prefix:
First Name:MAKENA
Middle Name:LIZABETH
Last Name:DETLOR
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:MAKENA
Other - Middle Name:LIZABETH
Other - Last Name:GUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:443 STRODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-5934
Mailing Address - Country:US
Mailing Address - Phone:608-338-3335
Mailing Address - Fax:
Practice Address - Street 1:320 W GRAND AVE STE 304A
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54495-2781
Practice Address - Country:US
Practice Address - Phone:715-424-6960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7240-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health