Individual
MAKENA LIZABETH DETLOR
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LPC-IT
Contact information
Practice address
320 W GRAND AVE STE 304A, WISCONSIN RAPIDS, WI 54495-2781
(715) 424-6960
Mailing address
443 STRODMAN AVE, WISCONSIN RAPIDS, WI 54494-5934
(608) 338-3335
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
7240-226
WI
Other
Enumeration date
02/06/2023
Last updated
02/06/2023
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