Provider Demographics
NPI:1164564522
Name:RICH, MARJORIE J (MSSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:J
Last Name:RICH
Suffix:
Gender:F
Credentials:MSSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4810 NORTHWESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-1504
Mailing Address - Country:US
Mailing Address - Phone:262-637-9984
Mailing Address - Fax:262-637-9995
Practice Address - Street 1:4810 NORTHWESTERN AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-1504
Practice Address - Country:US
Practice Address - Phone:262-637-9984
Practice Address - Fax:262-637-9995
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2744-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100027187Medicaid