Healthcare Provider Details

I. General information

NPI: 1265913958
Provider Name (Legal Business Name): MARY GOLDBECK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 NEWMAN RD
MT PLEASANT WI
53406
US

IV. Provider business mailing address

1700 S BEAUMONT AVE
KANSASVILLE WI
53139-9715
US

V. Phone/Fax

Practice location:
  • Phone: 884-888-0355
  • Fax: 844-222-4005
Mailing address:
  • Phone: 262-930-8824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8997-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: