Provider Demographics
NPI:1255736575
Name:GONNERING, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GONNERING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E WELLS ST APT FA601
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3579
Mailing Address - Country:US
Mailing Address - Phone:920-207-9613
Mailing Address - Fax:
Practice Address - Street 1:5228 W FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1346
Practice Address - Country:US
Practice Address - Phone:414-871-9111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17008-130101YA0400X
WI2235-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)