Provider Demographics
NPI:1265442669
Name:GORANSON, NANCY L (PHD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:L
Last Name:GORANSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8343
Mailing Address - Fax:
Practice Address - Street 1:430 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-4200
Practice Address - Fax:920-926-8885
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1826103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39131800Medicaid
P09522Medicare UPIN
WI39131800Medicaid