Provider Demographics
NPI:1265913958
Name:GOLDBECK, MARY (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GOLDBECK
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 1:1700 S BEAUMONT AVE
Mailing Address - Street 2:
Mailing Address - City:KANSASVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53139-9715
Mailing Address - Country:US
Mailing Address - Phone:262-930-8824
Mailing Address - Fax:
Practice Address - Street 1:1775 NEWMAN RD
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406
Practice Address - Country:US
Practice Address - Phone:884-888-0355
Practice Address - Fax:844-222-4005
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8997-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical