Provider Demographics
NPI:1871792747
Name:HOLDER-WILTZIUS, LINDA KELLY (LPC)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:KELLY
Last Name:HOLDER-WILTZIUS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 S LAYTON BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-1924
Mailing Address - Country:US
Mailing Address - Phone:414-902-1500
Mailing Address - Fax:
Practice Address - Street 1:1545 S LAYTON BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-1924
Practice Address - Country:US
Practice Address - Phone:414-902-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3551-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43590500Medicaid