Healthcare Provider Details

I. General information

NPI: 1407354418
Provider Name (Legal Business Name): ELLEN MARY WANNINGER MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 OVERLOOK TER
MADISON WI
53705-2254
US

IV. Provider business mailing address

17 N FRANKLIN ST
MADISON WI
53703-2307
US

V. Phone/Fax

Practice location:
  • Phone: 608-256-1901
  • Fax: 608-280-7291
Mailing address:
  • Phone: 608-201-2247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8808-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: