Provider Demographics
NPI:1003948522
Name:DETERMAN, MARY M (MSW LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:DETERMAN
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5757 W OKLAHOMA AVE
Mailing Address - Street 2:STE 203
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53219-4303
Mailing Address - Country:US
Mailing Address - Phone:414-431-6400
Mailing Address - Fax:414-431-6401
Practice Address - Street 1:5757 W OKLAHOMA AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53219-4303
Practice Address - Country:US
Practice Address - Phone:414-431-6400
Practice Address - Fax:414-431-6401
Is Sole Proprietor?:No
Enumeration Date:2007-03-10
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1174-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39737200Medicaid