Provider Demographics
NPI:1548250376
Name:MOGLOWSKY, NEAL ETHAN (MS, LPC)
Entity type:Individual
Prefix:MR
First Name:NEAL
Middle Name:ETHAN
Last Name:MOGLOWSKY
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8205 N 38TH ST
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53209-1513
Mailing Address - Country:US
Mailing Address - Phone:414-362-0327
Mailing Address - Fax:262-782-6937
Practice Address - Street 1:250 N SUNNY SLOPE RD
Practice Address - Street 2:SUITE 128
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4809
Practice Address - Country:US
Practice Address - Phone:262-782-2820
Practice Address - Fax:262-782-6937
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2836-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43568300Medicaid