Provider Demographics
NPI:1992884159
Name:BOHATKIEWICZ, MARILYN ELIZABETH (PHD)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:ELIZABETH
Last Name:BOHATKIEWICZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2200 DICKINSON RD UNIT 4
Mailing Address - Street 2:SUITE B
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-4056
Mailing Address - Country:US
Mailing Address - Phone:920-347-3500
Mailing Address - Fax:920-347-3501
Practice Address - Street 1:2200 DICKINSON RD UNIT 4
Practice Address - Street 2:SUITE B
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-4056
Practice Address - Country:US
Practice Address - Phone:920-347-3500
Practice Address - Fax:920-347-3501
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI1180057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39040500Medicaid
WI000207860Medicare PIN