Provider Demographics
NPI:1477661767
Name:GONWA, MARY JEAN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JEAN
Last Name:GONWA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E WASHINGTON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-2571
Mailing Address - Country:US
Mailing Address - Phone:262-338-2717
Mailing Address - Fax:262-338-9767
Practice Address - Street 1:279 S 17TH AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-3001
Practice Address - Country:US
Practice Address - Phone:262-306-9317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI796104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39708200Medicaid
WI84145Medicare PIN
WI68375Medicare PIN
WI39708200Medicaid