Provider Demographics
NPI:1134175334
Name:WHITMORE, MARY JANE (LCSW, CADCIII)
Entity type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:WHITMORE
Suffix:
Gender:F
Credentials:LCSW, CADCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 LAKE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1566
Mailing Address - Country:US
Mailing Address - Phone:262-634-8688
Mailing Address - Fax:262-634-7547
Practice Address - Street 1:840 LAKE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1566
Practice Address - Country:US
Practice Address - Phone:262-634-8688
Practice Address - Fax:262-634-7547
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7186-1231041C0700X
WI1623-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39341100Medicaid