Healthcare Provider Details

I. General information

NPI: 1265568968
Provider Name (Legal Business Name): LISA GOUTHRO APSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5703 MEMORIAL CT
WESTON WI
54476-6502
US

IV. Provider business mailing address

5703 MEMORIAL CT
WESTON WI
54476-6502
US

V. Phone/Fax

Practice location:
  • Phone: 715-204-9808
  • Fax:
Mailing address:
  • Phone: 715-204-9808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number135023121
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0128903-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: