Provider Demographics
NPI:1962135285
Name:VALENTINE, MARIA LYN (LPC)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:LYN
Last Name:VALENTINE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:LYN
Other - Last Name:WIEDENKELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11518 N PORT WASHINGTON RD STE 202
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3443
Mailing Address - Country:US
Mailing Address - Phone:253-328-7760
Mailing Address - Fax:
Practice Address - Street 1:11518 N PORT WASHINGTON RD STE 202
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3443
Practice Address - Country:US
Practice Address - Phone:253-328-7760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA113992101YM0800X
WI7624-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health