=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942215421
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MORESCO-GONIU PSYCHOLOGICAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2006
-----------------------------------------------------
Last Update Date | 05/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7733 W BURLEIGH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53222-5003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-347-8848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | N33W23374 GREENBRIAR CT
-----------------------------------------------------
City | PEWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53072-5721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-347-8848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CLINIC DIRECTOR
-----------------------------------------------------
Name | CAROL LYNN MORESCO-GONIU
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 262-347-8848
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1151-057
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------