Provider Demographics
NPI:1033463849
Name:GOGGINS, MARY (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GOGGINS
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 1:2607 N GRANDVIEW BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1686
Mailing Address - Country:US
Mailing Address - Phone:262-402-7964
Mailing Address - Fax:262-261-5062
Practice Address - Street 1:2607 N GRANDVIEW BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1686
Practice Address - Country:US
Practice Address - Phone:262-402-7964
Practice Address - Fax:262-261-5062
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-31
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15722-131101YA0400X
WI7947-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)