Provider Demographics
NPI:1114538162
Name:LUPO GONDWE, ANNE J (APSW)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:J
Last Name:LUPO GONDWE
Suffix:
Gender:F
Credentials:APSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 381
Mailing Address - Street 2:
Mailing Address - City:SIREN
Mailing Address - State:WI
Mailing Address - Zip Code:54872-0381
Mailing Address - Country:US
Mailing Address - Phone:715-349-8913
Mailing Address - Fax:715-349-8981
Practice Address - Street 1:24178 1ST AVE STE 2
Practice Address - Street 2:
Practice Address - City:SIREN
Practice Address - State:WI
Practice Address - Zip Code:54872-8220
Practice Address - Country:US
Practice Address - Phone:715-349-8913
Practice Address - Fax:715-349-8981
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI132006121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker