Provider Demographics
NPI:1114063690
Name:WANSERSKI, ANN
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:WANSERSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 E SECOND STREET
Mailing Address - Street 2:PO BOX 551
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452-2419
Mailing Address - Country:US
Mailing Address - Phone:715-539-8080
Mailing Address - Fax:715-539-8099
Practice Address - Street 1:712 E 2ND ST
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-2419
Practice Address - Country:US
Practice Address - Phone:715-539-8080
Practice Address - Fax:715-539-8099
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI424-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39608800Medicaid
WI002900825Medicare ID - Type Unspecified