Healthcare Provider Details

I. General information

NPI: 1245223742
Provider Name (Legal Business Name): NANCY JEAN GORANSON PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11101 W LINCOLN AVE ROGERS MEMORIAL HOSPITAL
WEST ALLIS WI
53227-1133
US

IV. Provider business mailing address

3630 N HICKORY LN ROGERS MEMORIAL HOSPITAL
OCONOMOWOC WI
53066-4532
US

V. Phone/Fax

Practice location:
  • Phone: 414-203-4480
  • Fax: 414-328-3737
Mailing address:
  • Phone: 262-646-1338
  • Fax: 262-646-7067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1624
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: