1194893966 NPI number — GWENDOLYN GRACE WERNER MSW

Table of content: GWENDOLYN GRACE WERNER MSW (NPI 1194893966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194893966 NPI number — GWENDOLYN GRACE WERNER MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WERNER
Provider First Name:
GWENDOLYN
Provider Middle Name:
GRACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOLDENMAN
Provider Other First Name:
GWEN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194893966
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W9203 BLUE SPRUCE LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-423-3960
Provider Business Mailing Address Fax Number:
608-423-7166

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
817 N MARSHALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-224-0800
Provider Business Practice Location Address Fax Number:
414-224-0883
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCSW438123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 106H00000X , with the licence number: MFT366124 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 39580700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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