Provider Demographics
NPI:1013022367
Name:WEBER, MARY MONICA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MONICA
Last Name:WEBER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6121 S 60TH ST
Mailing Address - Street 2:APT 2
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-1903
Mailing Address - Country:US
Mailing Address - Phone:414-421-4417
Mailing Address - Fax:
Practice Address - Street 1:1220 MOUND AVE
Practice Address - Street 2:STE 301
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404-3350
Practice Address - Country:US
Practice Address - Phone:262-633-3591
Practice Address - Fax:262-633-2619
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:2006-09-29
Deactivation Code:
Reactivation Date:2006-11-03
Provider Licenses
StateLicense IDTaxonomies
WI428-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39635800Medicaid