Healthcare Provider Details

I. General information

NPI: 1144289588
Provider Name (Legal Business Name): MARY J BRILL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4433 N OAKLAND AVE SUITE D
SHOREWOOD WI
53211-1600
US

IV. Provider business mailing address

4433 N OAKLAND AVE SUITE D
SHOREWOOD WI
53211-1600
US

V. Phone/Fax

Practice location:
  • Phone: 414-906-1445
  • Fax: 414-906-1445
Mailing address:
  • Phone: 414-906-1445
  • Fax: 414-906-1445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number3677-123
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3677123
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number24293
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: