Provider Demographics
NPI:1568452803
Name:GORE, MONIQUE L (LCSW)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:L
Last Name:GORE
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 1:3158 EATON RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6827
Mailing Address - Country:US
Mailing Address - Phone:920-819-3970
Mailing Address - Fax:920-600-0271
Practice Address - Street 1:3158 EATON RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6827
Practice Address - Country:US
Practice Address - Phone:920-770-3319
Practice Address - Fax:920-600-0271
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2023-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7158-1231041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43562500Medicaid
WI43562500Medicaid