Provider Demographics
NPI:1801621669
Name:VAIL, MARLENE DIANE (LCSW)
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:DIANE
Last Name:VAIL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 S LOWER GARDENS RD
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:WI
Mailing Address - Zip Code:53125-1102
Mailing Address - Country:US
Mailing Address - Phone:262-903-0784
Mailing Address - Fax:
Practice Address - Street 1:W4063 HWY NN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4338
Practice Address - Country:US
Practice Address - Phone:262-741-1440
Practice Address - Fax:262-743-2221
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11373-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical