Provider Demographics
NPI:1689772667
Name:AMUNSON, MARY ELIZABETH (LPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:AMUNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8225 N POPLAR DR
Mailing Address - Street 2:
Mailing Address - City:FOX POINT
Mailing Address - State:WI
Mailing Address - Zip Code:53217
Mailing Address - Country:US
Mailing Address - Phone:414-247-3720
Mailing Address - Fax:
Practice Address - Street 1:12425 KNOLL RD
Practice Address - Street 2:STE 110 WEST GROVE CLINIC
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122
Practice Address - Country:US
Practice Address - Phone:262-780-9788
Practice Address - Fax:262-432-0045
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI2534125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39402800Medicaid