MEDICARE: MARY DETERMAN MSW, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	2357	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861524365
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY DETERMAN MSW, LLC

Provider Business Mailing Address
First Line	:	5757 W OKLAHOMA AVE
Second Line	:	SUITE 203
City	:	MILWAUKEE
State	:	WI
Zip	:	53219-4303
Country	:	US
Telephone Number	:	414-431-6400
Fax Number	:	414-431-6401

Provider Business Practice Location Address
First Line	:	5757 W OKLAHOMA AVE
Second Line	:	SUITE 203
City	:	MILWAUKEE
State	:	WI
Zip	:	53219-4303
Country	:	US
Telephone Number	:	414-431-6400
Fax Number	:	414-431-6401

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MARYELLEN ROZGA
Credential	:
Telephone Number	:	414-431-6400

Provider Enumeration Date	:	03/10/2007
Last Update Date	:	08/22/2020

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