Individual
MARIBETH ROSE DETTLAFF
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MSW, LCSW, CADC
Contact information
Practice address
500 RIVERVIEW AVE STE 2, WAUKESHA, WI 53188-3632
(262) 548-7399
Mailing address
W168S7024 PARKLAND DR, MUSKEGO, WI 53150-9441
(414) 422-0708
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
12548
WI
1041C0700X
Clinical Social Worker
521-123
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
39572300
T-19 PROVIDER NUMBER
WI
Enumeration date
12/21/2006
Last updated
09/11/2025
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