| Doctor Name: | MARK WEITKUM |
| NPI Number: | 1063647147 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | SAC-IT |
| License Number: | 13705-130 |
| Business Practice Address: | 797 E Geneva St Elkhorn, WI - 531212303 |
| Business Phone Number: | 2627231455 |
| Business Fax Number: | 2627231556 |
| Mailing Address: | 285 N Janacek Rd, BROOKFIELD |
| State: | WI |
| Postal Code: | 530456102 |
| Phone Number: | 2626419050 |
| Fax Number: | 2626419126 |
| NPI Enumeration Date: | 05/19/2009 |
| NPI Last Update Date: | 05/19/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 13705-130 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |