Healthcare Provider Details

I. General information

NPI: 1902215049
Provider Name (Legal Business Name): MARY GRACE BAUMGARTNER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2014
Last Update Date: 01/20/2026
Certification Date: 01/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 RIDGEWOOD DR
WEST BEND WI
53095-5501
US

IV. Provider business mailing address

1412 RIDGEWOOD DR
WEST BEND WI
53095-5501
US

V. Phone/Fax

Practice location:
  • Phone: 314-974-7040
  • Fax:
Mailing address:
  • Phone: 314-974-7040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8552-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: