Provider Demographics
NPI:1235425885
Name:PASSAGE, MONICA M (LCSW, RN)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:M
Last Name:PASSAGE
Suffix:
Gender:F
Credentials:LCSW, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 WARWICK WAY UNIT A
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-5661
Mailing Address - Country:US
Mailing Address - Phone:262-789-1191
Mailing Address - Fax:262-583-4014
Practice Address - Street 1:1143 WARWICK WAY UNIT A
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-5661
Practice Address - Country:US
Practice Address - Phone:262-789-1191
Practice Address - Fax:262-583-4014
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3819-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1235425885Medicaid